0303-026 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
777699 B �4l3tFli?
i
Date �' Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structur.'e.is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) , I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor,Code, for the performance of the work for which this
permit is issued:, My workers' compensation insurance carrier & policy no. are:
Carrier 1,114EitTY J'+lti7.'UAL 1': Policy No. W.-V,62D0D47,3012T1
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall f rthwith comply with those proyjsions.
Date: Applicant s &15�4 (X,7:,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 9� l✓Date
BUILDING PERMIT PERM' �,,�,
DATE�J/, � VALUATION,3 LOT$ TRACT
0y5
JOB SITE
ADDRESS 80-M3 VIA'nRRA � IA
APN
772-2W-0,10
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'11'9LL T";iZaa1% m WIC
INC
'73.121 FRM3WAT'ti'J G *100
7 3-121 Ia:ktTe"C9 WAIt IM0 4100
PAt.:MDEa '.Et r Cts. 92260
PAeC M T7 ES'Jrr�R�tT` �:.i��/ 92/J260
{ (p� /ry�
(760)674-9699 �,aldl 3832,
USE OF PERMIT
MWG I7 FA7 mly D'i�i:J:+:i.J.,T.l+1C",
--SF7) - LOT'24 SEDONA -.A.. PER.t IT DOM NOT INC1XID F, BLOCK
VITAL FA POOL, SPA OR D3,11 ?.'GVAY APPROACH
t,'IUSUtiJbi, CONSTRUCTION 7,80.00 Si'
P0Rc'H1P.ATIO 275.00 SF1
(JAIZAtTF�' ARPORT - 610, 00 SF
E9X I.MTIO) COY 01 C'C)!YS'MEJC';Ci:014
PER.i W 1t EE ST1 VIARY
CONSTRUCTION ME., 101.000418.000 $1,103.98
PLAN CNF',C"rC
J iZeCHANICALFEE 101,a000-421.000
ELSC'P.F CAL 141Z 101-000-4203-OC4,
PLtfMkiMOnZ 161-000 1.19. 100 5134 Oi+
STRC( CJ IbOTION.YVE MID 101-000724.1-000
O)" ADINO PUK 101400-423-000 $13,00 •
DEVELOPER JMPACP FE11,
A1F;r IN Punic Pl...f cE3 - Rmsu 27th-boOA45-000 SK33
,y�yy �S. *{ /� 'q �y �y1 p �v�!� ��r
^ } 's i� A ' ��. L'O.t;7 s�.1:�.�,i.'rl.��.�1.,'.les.i?�i ) .i .I.ut w- <..F.d.�cx
�{ /per
$1',005,90
D �. U33 PRE -PAID INW-3
$0.00
APR 1 R 1003 AL PmkurMIS D NOW
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT.
DATE/s
t /. r
BY T AL
�.
SPECTQQ
/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
i
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
"
i
Final
Final
M
POOLS'- SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-'04-6-3
Heater Final
Water Piping
e2ePlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_D J7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
,Underground Conduit
"
Rough Wiring
Low Vobge Wiring
Fixtures
Main Service
-
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
'
LJ "A YV7
Final
j
Utility Notice (Perm)
•O