0209-144 (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
771699
Date' �� Signature of Contractor/,I
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 structure 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).
O I am exempt under Section—• � B&P.C. for:this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
r
I hereby affirm .under penalty, of perjury one of the following declarations:
( ) • l,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 pAC1JF1C! i6,+IPWV-1M Policy No. WR C430.343I$
(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
/Do'de, I shell., forthwith comply wit hosg,'
ate: `� ,T, �� Applicant &),
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building'and Safety
for a permit subject to the conditions and. restrictions set ;forth' on his
application.
A. Each person upon whose behalf this application•is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work isnot commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) - Date•
.-
BUILDING PERMIT PERMIT#o
DATE VALUATIONLOT + TRACT
JOB SITE _
ADDRESS ( G�"Q V.rAi i R A �
APN
7 2--�iSiA•�M
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOLLBR.0'X°r}.��.�J.Wo
1/4.923 TI- O EKIA LME ZWV 31ITM220
74.5923 :CT(;P'S ELY LAIMt ` 3TAN Vii'►.C'�+ te t
MUM DAt.;�Mr CA 92260
��''f��.1f I' 3° CA
�'�9:17fAi�,,
yp92260
(760)(774-9699 �-YF .0 381,12
USE OF PERMIT
3FD . L07'147.$ S:h.NTA ROSA. P&A1y1IT DOES 140T 11.CLUE)F 13LOCY
WALLS, i OOU SPA Olt DRIVE',WA YAPPROACH
4 +
CV31TOM CONSTRUCTION/904/100 U2;
NC71Y.C1!212'A�'2O ��I.Oti Sir
OAPAOE1C:ARP OR,T 756. i0 31?
XSTMUMD CONT OF COKS.Mucvrulliq
3191:5150.70."
C•tOAS 'I). l�ri�'fi� LRUCq"y10101-000-4,18-000 ��3g3'.�Jrq.,�0jk4,1 y
7(87NOp00 Q$i,3�gg.�u{0
P2.."c.I3i�. IK�',S d016"61C)tA� 3} 71U I,Rlb.J7
MECHAMICAL TIM 1011 0("_ .21 MQW $1131.00
2 2yWI'22IC ;!?,.T.. PER 01-000-420.000 -^000-420.000 $207,06
PLIUMBINO Re, `01 -000-419-000
YMONIG MOT1014 I VE • Ff.EMID 1011-000=2A I -000, ` VIM' '
Ofi,p,;M90 TARE 101-1000.4-23-000 MUD,
131 V1YLOPLI : IMPACT Tri 1��r40°5 a�D
ARTIN PUjR,+IC'2 P WS.. WK 170=000-445400 $776.38
t• y? ppttt�f �r
•7 nmgr•Mn �.r AND
SUB -TOTAL 0011 t 2 a..e�,.ldo:.P. �,��aru AND P S.,JAYi�7 5:I.1"7.� CY,
Ly q d9
IEW3 PTM-I AID
$0,00
a
'X.✓ 5. J'v.4 �SY.�I. . �' � a �bS .l: 7'f'
13Y3i�P..d 4'7a
r2SEP'7 2002
CITY OF LA QUINTA
FINANCE DEPT.
�ECEI E..,' BYE
DATE FINALED
INSPECTOR ',
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
E aust Fans
O.K. to Wrap
.U.
Framing
_
ompressor
Insulation
�` —
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Z -
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
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
_
Waste Lines �Z
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Tap Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral�
Pool Cover
Sewer Connection
Gas Piping
Gas Test
_
2! 7l
Encapsulation
Appliances
Final
COMMENTS:
Final
Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)