0312-028 (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 # r` Lic. Class. Exp: Date
�7T169R
Date ��`U Signature of Contractor
OWNER -BUILDER DECLARATION,"r
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License -Law for the following reason: s
( ) 1, as owner of the property, or my'employees with wage's as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business &,Professionals'Code).,
as owner •of the property, am exclusively, contracting with licensed
,contractorst'to construct -the project,'($ec. 7044,.Business & Professionals -
Code). !• "
( ) I am'exempt.underSectidh B&P.C. for this reason
Date Signature of Owner = }
. r i—
+ WORKER'S COMPENSATION DECLARATION v
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.
�Or I have and',will ;maintain workers' compensation insurance, as.required by
SpctionY3700 of,the Llabog.Code„ for the performance of the. work for which this
permit is issued.. Myfwoikers': compensation insurance carrier &'-policy' no are:,
,Policy No. .
Carrier ' LIDEM,Y W.!'fOAt Y. r�/�a2fi2%i0R4 �3i3F2 ' ,
(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 forthwith comply with those provisions`_ �
.Date: f1`l/ APPlicant, e^
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 prope rty°fog inspection;pdrpo ses.
Sign'atu e� (Oner/Agent) _'�'
( •BUILDING_ PERMIT PERMIT#
DATE j ' //VALUATION .' - ,.� A.ry LOT' 99• 0312 TRACT
• a� a� r
`� r
30357
303 S
!
f
JOB SITE +
ADDRESS 61.0 VIA TALL• MA
APN
'772 '
OWNER, -�
CONTRACTOR/DESIGNER/EN (NEER'
UL:,133t.O'i 15rSC
' OLL �t5 �����# %fig
?,f• 4 DT +s �l?'f Cit t3 26Q
7r� P�f iit?�i ia'4 d"p�{�
(760)674-9699 CBrul 38,62
USE OF PERMIT
�' Ciil Jt Y i7W1'n_e..<CWC
i
R ' W -r iu, t,3tfdN'T.o NA -11, "PI RMIT.BLOCK
O PMieWAY APPROACH
,
r
6MUM CONST'RUCTIO'N 1412.00 SF
a
/aOpp }%cyCppkrrlPp�A�`t��'1yy0��j,/:�. q9 (. 6320. [000 [�;F
Mdliil`iA`i_Lfi��rf'!RV Fi:.2 - 4Pe49a s J
-
r3e"1' 7 ' ? i>i3 IT 4)Ilj CCANSMUCTIOV
CONSTRUCTION FEF 101-000-418-0 00. $1,280,00
i'3I N, cHrX1C "X .101-000-439-318
SjAECr.1-IAl(�ilcf:�.dgtl�}. EE; , 3(��y1-(®0100 �pl?{44.501
+,t0t-42
�-p0
'��ICeA.IFIn.,.'S41�rJ-Jr'AWJ. '• f ZC/i••Q01,J:..1.GS/••SJUSI ,p.�.G1 Y.JW
' .
Pl:t3.i� tl3aCtl!s;C; . , 101-000.419-000
,°ti't IZ0140 ,N:01130,N FRE , RESM 101.000-241-000
ORAD410 HE 101-000-42.3.000 S i x.60
I&MVELOP1F..1 _i>+i$PACt �r� ,fas.o�
Akl 111.1 PUBLIC PLAC&,� - RMIE L'1�'7•QO@-44�-GQi7 $205.90
.n T -TUXAL CON: TRUC°:1:109 AND PLAN CHECK
$5,462.44
DEC 12 1003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE; T
BY j!�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
11
MECHANICAL APPROVALS
Set Backs
Forms & Footings
nderground Ducts
Ducts
_ _
Slab Grade `d
Return Air
Steel W
Combustion Air
Roof Deck
Exhaust Fans
+
_ _ _
O.K. to Wrap
.U.
_ _
Framing
pressor
Insulation
Vents
Fireplace P.L.
Griffis
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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 AP
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 61902
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
u