0002-134 (SFD)LICENSED CONTRACTOR DECLARATION
l.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
674074 " D 07/3 1/2(
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 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).
() 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 `•.'TATE FUND Policy No. 046.000: 38
(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: 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. '
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)
Date
BUILDING PERMIT PERMIT#
0002-134
DATE „ VALUATION-S240s.11-7.10 LOT 35 TRACT 25306
JOB SITE
ADDRESS 1�,, "VI�I',t`A CALJC0
APN 4049- I.(?"319
OWNER
CONTRACTOR/DESIGNER/EN INEER
TD 1) M,RT T.fiMOP1vdP..W
SPARX3 CONS'I'RLTMAi
PO BOX 1716
'19.295 RAN C1110 LA QW'MDR,
LA Q(1iiNTA CA 92253
L A QUDTTA CA 92.25'1
(760)771-1941 CBU 2996
USE OF PERMIT
'C;1,1r k.AM'l1:. Y MMUN G
SPO -LOT 53,PL;AN X20R. PERMIT DOTS *NOT INCLi DY, BLOCK WALL4 OR
P001.15% P -JAW C.HWX F`I7.E W&DUCTIOW FOR MULTIPLE ISSUANCE OFF
SAME: PI..Ri14 TYPE.
CU1+TbM COINSTRUCTFOW 71924,00 OF
I'faRMPATIO MOO Sr
C IIR AC3FIO ARPORT 470.00 SF
ESMWMD LOFT OYI, COMMil!MON
240,11.7.10
PE, RM :' F -EE SUM.Y
CONSTRUCTION FEE 101.000-418.000 $1,133.00
PL A14 CHECK FEE 101.000-439-318 $232.24
MCHANICA10 FEE, 101.000-421-000 $130,50
EI..Pt TRIC -AL FEE 101-00•420;-000 $169.24
PLi3P. BFa'40 FER 101.000.419-000 81.75.75
STRONG MI CITION FEE . RESID 101-000.241-0013 $2.4.01.
ORA-DINO FEE 101,00Q-423=000 520.170
DEVELOPER IMP.A.CT FEE $],9fYa.ijO
{SRT 1W PUB IC PLACES - MOE 7131=000.255•-1100 $390.29
SU:-840TAL CONST'1MMION A14D X -AR CHECK
$4,142.03
= MAPAIDPEFS
$0,00
:L(YJr L rERMF'M. M. J]CIE NOW
$4,1.4.2.03
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
<5�: t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7 Z Z,
Underground Ducts
Forms & Footings
Ducts
Slab Grade
— Z Od `
Return Air
Steel
Combustion Air
Roof Deck
�
Exhaust Fans
O. K. to Wrap
/
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
Final
Final 441 1 4
BLOCKWAL ROVALS
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
Gas Test
Electric Final
Waste Lines
.—p0
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
Appliances
14
Final
/01
Final
Utility Notice (Gas)
ELECTRICAL PPROVALS
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) t
COMMENTS:
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisionsfof
Chapter 9 (commencing with Section.7000) of Division 3 of the Business ap��
Professionals Code, and my License is in full force and effect.
License # Lic. Class - Exp.. Date
c 7du 4 13 io 7/_5 is it' s
'Date _ 7 Signature of Contractor
�f ✓ rpt
J,:• _'�-J OWNER-BUILDER-DVARATION • ,
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). s -
( ) I', as owner• of the ,property, am exclusively contracting,,with licensed
contractors to construct the project, (Sec. 7044, Business &'Professionals
Code). �- ` • r' ° ,
O f am •exempt under Section ' B&P.C. for this reason
Date 'Signature of Owner A' '
.� WORKER'SCOMPENSATION DECLARATION
I 'hereby affirm _.under penalty of perjury one of the following declarations:
O 1 -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. 5
( ) I have and will maintain workers' compensation insurance, as required by
Section 370.0 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 ' Policy No. - '
c a 5'f'S^.,5 rr•tth 5rm -..r.t�r"••2�e+..
- ''. Cl, 6..5;.1 !J lYrJ .. VdV •'t.+?%I!'r .l:JO
(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: 'Applicant • �'� c
Wa7riit a:-A`ila a to secure Workers%Compens�on coverage is unl�•Lul and
shall subject an employer to criminal penalties and civil fines up to $160,000, in
addition to the cost of compensation, damages as provided for in Section 3706 t"
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 Ito .the conditions and restrictions set 'forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request andfor 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 Ouinta; 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 1 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 pu'rpo'ses.-
Signature
urposes:Signature (Owner/Agee) `_'- ' �1 DateZ
BUILDING PERMIT PERMIT# ;
4fW 43 4
DATE VALUATION LOT TRACT
35 3tX
JOB SITE
APN
ADDRESS .•B<8-bpi"l+Ji.i� lkA'A,,�C4_
��--BCU-�.&�7; -
'0
OWNER CONTRACTOR / DESIGNER / ENGINEER
• �e rh �•ir:ct"T57 r1t~��x;i e^a•�Tca�i~,�i•�-• �,,, ' �nl�lZ''.�a r-1�?.r� ZIT �rroa°T��,'1 .-' '
3 I.t,., f',. .. i.!1.�61,.r1,'.J _101.,,:.1 'P •1�,,'�.� {..,1 ..1 1. tom. Ilryl .V L,t IS.J!' -
t�� � t`'A 1 11 !4- :3%it1.NC:a-.itJ Wi,?Uri�'.'A t .
I.'.A.QiJtiv`:t'ri Qk Y22-54-.t.,A QUtNFA C''A 922-53
USE OF PERMIT, w • A %
Z3,F1 i6-1 is VA1mYiLa 6W1✓i.,l...iNO
2,1I-D>.L0 Y Is .t°.'[,AdV 1'.2, 1AER v T.D0E.8 NO T 32S ,;.i.'e ME, i31LfaM'WA U.8 017,
114 iLi1..73.i./1,N'f>f•fV,CKI-FJ RI---' UC°1`1:0N 10-kNft i l,'i'ila1A." iSaUtV4C.E0
A 11
. 111J'lii.E' �'I(Z�fIA.tV ..'.4145.00 SS'
U M..r\+.it"s C./1APf,i1i`i' '41"
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1
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r
`
�OM�3'i'9�T.1�.'k°I.�JTi;�t�i I.UI•�t}fJt�-�I.t.t3-i?Ut) $1.I�3.tJt)
>�s.c�t�f rs•r►;cMs: rte tttl-ttaTtl-•�.3rJ-'1'tit !�h37 4
'
:- i:5.l;1. UVSt"*iG11.::r6riAlln5d _ - .45
.V. -X31 U Jir4r , 41
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t•.
PL.t,1-t W [N43 -VE61 10.1-000-4194)00
sB'{tf'!'f5it , ar cYr't('1tJ'rru t gs in I (i 1 non-7iii _0'(10
l�.t<'.i':t:N .tit:►tdl..f:�.;1'.i;.L:�t S._,EL33�3fi: "Y()1-U(!t}-`L��-tt()t) a•t�U.'vy
-
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Wil.
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Irl Iea2 01
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;s,�ji42.�S
RECEIPT
DATE
B'
DATE FINALED
INSPECTOR �';w;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
Underground Ducts i
Forms & Footings
Ducts
Slab Grade
--CIS
Return Air ]
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents {
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Al
Final _ —Q
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
Gas Test
Electric Final
Waste Lines
_
— (J. mac!
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
Appliances
Final
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)
COMMENTS:
'