0311-193 (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
7771699 D 4130/'04
Date
to l Signature of Contractor"w `..� - ---•
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
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 LIBERTY MUTUAL Ir Policy No. WA.2t W04'363D12T1
1
(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
workeAs''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 rov.sion _
Date: i'1 Applicant /
F.
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 a O
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to, & shall, indemn'
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and v d if
work is not commenced within 180 days from date of issuance of uc
permit, or cessation of work for 180 days will subject permit to cance tion. C
1 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 building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
'Signature (Owner/Agent) `• o ✓I�m�&r�. Date /1 `"�<
PERMIT #
BUILDING PERMIT,:���_�
DATE VALUATION LOT TRACT
2:1;2I."a�`� 1:45 30357
JOB SITE
ADDRESS 80-625, V rALAVE
APN
772-d704W
a/
OWNER "'
CONTRACTOR/DESIGNER/EN (NEER
'r OLTI B 1Z0TBffW DTC
anu Bre o mms aid,
73.121:1TtTO WART.NG 9100
73.121 +e M- W'.P'� NGro100
P.aALNt Dr112'1:' CA 92260
17Ai 1`vS DE:S.Wr CA 92260
(760)674-.9699. G'auf ' 353
USE OF PERMIT
SWIDLE F"ILY DVM 1MG
sru) • F CaT 135, hVIZAMONT&B, :P.E.T?&]IT DOF s NO IIQCLUDtP BLOCK
11'dAW, POOLSRA OR DRPtI'k,tVAY AP1 K0, tsCH
CUSTOM CONSTRUCTION 3,847,00 SF
FORC H/PATIO 531.00 SP
iAJ(A0F_J ";A,RP0RT 752.00 ON
EsT D COST Ora CONEM')SiMt' N
3.71.081.63
PXRhQT 1'1 F S'lT: h'�. ARY
GN1i'UTION FP -,F' 180 00 SJA1, 3•«D
4 "
•101•.000-
PLANFEB- 10101-000-4S9-3is �d.;I49.Za
MEC-HANICALFrZ, N 01.340-121.1700 $00100
ZLEC'f PIC::C L PEE . • 101-000-420-£100 $205.69
%+t1Iti9: f�ic FEE101.000.419-'100 S19t'.00
STRONG MOTION Ft =liE II:! 101-0001-2A I -000
{31dADINOF.tl 101-000-423.000 St 0
OL.Vr,'LDP: IMPACT rf= ��,Cf35.00
A TIN PUBLIC PLACES - HESIE 270.000-445.000 8344,70
91'313-TCYDAL C�ONt rl.l"* 0C -LION AMPLAC:I�]:;M
$5,868, 0
4 PRE-PATKKUS
$0.00
DEC : TOW, rX�ff FF_Es DOX, NCYW
l
'NA�cF
Fia7�T9 :.
RECEIPT
E
/ E ,/ . / •
BY D I AL
�r./ f .
— If
INSPE OR i
r2a
QTIIIIIIIIII
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROV S
MECHANICAL APPROVALS
Set Backs
Forms &Footings I
Slab Grade
Underground Ducts
ucts
Return Air
-
Steel _
Combustion Air
_
Roof Deck
Exhaust Fans
_
O.K. to Wrap _ _ _
Framing _ _
Insulation ,
F.A.U.
Compressor
Vents
Grills
_ _
Fireplace P.L.
Fireplace T.O.
Fans & Controls
Party Wall 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 APP OV LS
_Electric
Waste Lines / _
Water Piping _
a
Plumbing Top Out
Gas Test
Final
Heater Final
Plumbing Final.
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _ _A
Pool Cover
Sewer Connection �(,
Encapsulation
_
Gas Piping
Gas Test - _e;
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)