0210-286 (RPL)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
77i
Date Signature of Contracfor��
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).
( . y . 1, 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
per of the work for which this permit is issued.
k"°.),h l 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
r.r;permit is issued.' My workers' compensation insurance carrier & policy no. are:.
,',Carrier: VATE 4:OMPIf:4tS,r TI Policy NO., 0461DIM163-1012
(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,
a ,1`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
4•' subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thosprovlsions.
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.
A 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'l 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 f purposes 'e •'
Si ~nature (Owner/A ent). Date'
.t PERMIT# '
BUILDING PERMIT
VA
DATE LUN LOT TRACT11-
» .v: $24M ,
ADDRESS:A� I(�?i;�-AVaukA�i✓N JOB SITE
APN _
OWNER
CONTRACTOR /DESIGNER NINEER
Sf 13EVG34cWVFJ.
C1L110k'1nYOOU &,Tf'yS (J`t qA a
Po BOX 17 i 6 V€
6.100 AVIWJI? 5.4
LA F,QUON A CA '92253
COACkilELLA. CA 92236
..,
4,
(760)398-92-22 CM41 00355
USE OF PERMIT
POO), ANIXOR VA
.. iiiA, ,l1 BE rN PLAcj.AT PRF,. LA�S"Tsp� i(ew iOd+ri. GCZ�1LAi %�d'i.'
P001, ANUOR VA 24,000,DD US
EHM AIXI3 COST OF C ONSTRISM V9C'JtM
P'fKiZWUI'ru &iMMARY
PLAIN Ci'lWK FRE 101-000-439.318 $137M .
CCi.tiST-RU TiGk1 M10, 101-OC>;04191.000 VA3.00
MECHANICAL FER -- POOL 101-000,421-000 124.00
iG1j;IGT RRC,A.L .FEE, —POOL 103 -WO.42•0440 $45.0
f4UUNG FRE ,.1100L 101.00.0-41.9-000 527,00
_ 3iJA`'^M`l't^,TA1.:;> -. ?IUCT ,fJN iYb1D Z3X.AN C1
OCT 3 6 2002 . � �At�,.�a��.�.�r�;cw�►�
CR OF LAQUINTA
FINANCE DEPT,
RECEIPT
DATE
BY
DATE FINAL
INSPECTOR
a?,
ii
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air G
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
_ Z
Approval to Cover
Equipment Location
Underground Electric
Underground PINI. Test
Final
Gas Piping
PLUMBING APPROVALS
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
Gas Piping
Encapsulation
Gas Test
Appliances
Final L2, —
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:
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#4 BARS @ 12' O.C. EA -WAY.
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WITH STL. REINFORCING.
FIREPLACE DETAIL.
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