0401-150 (SFD)LICENSED CONTRACTOR DECLARATION
n 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
LProfessionals Code, and -my License is in_ full force and effect.
e) License # Lic. Class Exp. Date
J
7 -7 7 6 9.9 B 4/2110/04p
04
L
y
Z r Date Signature of Contractor "�✓,�' �,/ ��� r'� ^^•-w
J. r
C� OWNER -BUILDER DECLARATION
Li I hereby affirm under penalty of perjury that I am exempt from the Contractor's
nLicense Law for the following reason:
Z ( ) 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
N Date Signature of Owner
C\J _
L^Q WORKER'S COMPENSATION DECLARATION
Z I hereby affirm under penalty of perjury one of the following declarations:
L p O 1 have and will, maintain a certificate of consent 'to self insure for workers'
3
"`compensation, as provided' for by Section 3700 -of the Labor Code, for the
�
Q performance of the work for which this permit is issued.
(V (';,,z)' I have and will maintain workers' compensation insurance, as required•by
Q Section 3700 of the Labor Code, for the performance of the work for which this
� H ` ' permit is issued. My workers' compensation insurance c�rrler & policy no. are:
t z Carrier U13d�:EM'. MUTUAL K. Policy No.
'(This section need not be completed if the permit valuation is for $100.00 or less).
s O 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
3 subject to the workers' compensation provisions of Section 3700 of the. Labor
Code, I shall forthwith comply with those provisions.
Al[Date: 0—;465/ Applicant ef'Jn �ge' oe _ x_62 -»
Warning: Failure to secure Workers CorSipensation 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 Applicatiori 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 suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information '
correct. I agree to comply with all City, and State laws relating! to the build; g
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for inspection purposes.`
e r
Signature (Owner/Agent) 4W k��.Ca.,✓ Date
BUILDING,p. PERMIT • PERM' 0401 10
DATE VALUATION itY312,146.70 ,LOT 13s TRACT _.30357
JOB SITE WSW_ VJA TALAWRA
APN
TM -2'70.0 02.
ADDRESS
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
70LIA1.13RC3°% ERS 71KCr
TOIL MO;l31ERS INC
73.121 FRED WA14ZNG Ih 00
73-1217' RT31 , WACt:M41100
PAIMILNMRT CA 92.260
PA'IMMYESER17
(760)674,,9699C:i3t.
3 St 3a'.'
i
s
i
USE OF PERMIT •3' * qy DM LAW
ws ♦ •• x.::^. a aag a>•.oa"• .e awywa; a -u •a . +. _ . v w
POOL, r5PA-13LOCKWA.LT4,Citi Mfr'iVF1uJ.t!Yr;PPtROACH,
,
CUSTOM CONSTMv - IONV,41.60 BFPC3Rt•.HIPATIO..:,
't
.
444.00 SF
C Alt Atyf2lC t'l1Z tJ �, 756"an 6F
l:a`�S'.�' OPI CON►�r" M-PlION
312, .4630 '
le y j yy+ {•pe^�,yg � � •� -'a
PIF ",W rim" LTiJBVR.AV,�.6fYM
CONSt'RUCTION FD11 101.0004418"000 , ,' • ' sot"S.00
MAN CkTi?.Ci,'. +'E1,
MECHANICAL RM 1011-000-1-21-000 " `. $118,itCi
101-£100-42>, -000 $30.106
P>,,UA6i31 40 YEE 101.000-419-000
S'1`1:.oNo PJIonm ru Rum 101 !1(ii7- 1-000 X97:87
+.312ADR90, VRE' 101-000.423-000 $15.00
OT' ZLOPE:•1} IMPACT 1r& $A445.00
API T T!4 PIJ.Kic PLACES - PTIesit .270+e000.443.000
SUB, i(YIM.Ct"3W1F2TUMICf.NA PT"` CTM C..
gyp• �r+A.7 •t Tpq�If�6*�+ Ft f•�. �7q-�ta�
-•i:ter, 101AL J.y�..7Y.AV' f ��F,S 1i �. J, -i i qC-P:i•V
• /�-,�� _ -_
p �p�t q
$555,7441.43
$555, 7441.43
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JAN 2 U� 1 i'.j
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'
CITY of i
F1ib•A1w,
RECEIPT "DATE-_j"BY
I E
_
t. 7
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
_
O.K. to Wrap
F.A.U.
_
Framing
Compressor
Insulation A -
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 7
_
Final
Final .
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 APPR VAI,
Gas Test
_eell _
Electric Final
Waste Lines
Heater Final
_
Water Piping
Plumbing Final
Plumbing Top Out (
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection „ _ _
Pool Cover
Encapsulation
Gas Piping
Gas Test S• m
Appliances
Final
COMMENTS:
r
Final
Utility Notice (Gas) — —
ELECTRICAL APPRO AL
Temp. Power Pole
Underground Conduit _
Rough Wiring IQ
_ r
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)