0111-240 (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 �'�-. p. Date
6 1144917
Date r < Signature of Contractor r `-
OWNER-BUILDERDECLARATION
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 isnot 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 pet mit 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 Policy No.
(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 Californiaa,and agree that if I should become
subject to the workers' compensation.:provlsioir s of Section 3700.of the Labor
Code, I shall fortl4ith comply with those provisions. J ,f
`Date: rT V Applicant `
Warning: Failure to secure Workers' Compensation coverage'' is.unlawf' and
shall subject an employer to criminal penalties and civil fines up to $100,00, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. !
IMPORTANT Application is hereby made to the Director of Building and,Safety
for a permit subject to .the conditions , and restrictions set forth 'on his
application.
r=
1. Each person upon whose behalf this application is made & each person'at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to., & shall,- indemnify
& hold harmless the City of La Quinta,,its officers, agents and employees.
2. Any permit issued as a result of. this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have'read this application and state that the above information is;, i
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize reprt@sentatives of INS City to enter upon;,
the above-mentioned property for 'Iinspection`�purposes ,, -
;P°
Signature (Owner/Agent] !' x � Date '� ��
BUILDING PERMIT PERMIT#
DATE 1 VALUATION LOT 01,11`"240 TRACT Y
two l,I?J0 73 29-437-2
JOB SITE
ADDRESS-'�aS�Pr.dQL .FS a$ifA
APN
%•RM^07
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M?11F"1PkCa.•C11t17i
110, DOX 716
Yr:>'s QUMA CA 92M'
LA, Q '.�'TA VA 92233
(Hall)"T"'a 1 � i 941 CS1.4 x:996
USE. OF PERMIT
dAWyIT+1LY DW M1240
.
JH- .LOT '73 P4,AN ;tZ )• MIT i tOESINOT INC1.Ui•3Z 8).,01; X WAUS.,
P001, 9P, A OR DRREWAYAPPROACH
s
C014STRUC T1014 2,9240q
rtw".Iy�•
rys�A4
SSP • Y t�\.a,t 37 A".fF 7l ii:+� AYE .�V S
l'?�+.i�1?.��[�.1C:•,rl.1��'�.�'� �'7ti3Oft 5�
FUMIA17D OF CONYndle, MR
240,11 7.1O
7r:.,ro;�ti��2`j.g'i+V`��y�Egyu�?lab�.��'t, Y
'h-\�%f�11��iCJ 1!rC 1'�9L7' L;A�..T.p ,i Cif ^\'!V'�+^'�'.E �S"V`i%1,+ O,i�.d.YJnM�
•
T;:;,AN MM* PPF. 1014100439-318 $33.1.24
EG'HAMCAL F 101-000-421-000 $P$U,60
ELECTRICAL FEE, P. U R-C2Dt?-�b2tE-i?Q�► $kb9.�t
v?lril'Ar313'�'�i� ���> 1 Cl uC1t1C3�01 S�•=l�t1U �lig.�°3
u i'I'.'�O7n9L91yiiO"d`$:t N, 11M.11,211D 101-000-242-000 $34.01
O}}A��y+y.��p6O F&F,101.0(' 0.473.0 0 $20.00
y�`quse "A`� gp1
DZY
fi�e.4�,`f�` ni Punic Pwis,. xF r 27o-000,-44:5 tooC $100.29
,yi' /QST
PIAN �IVAA�X.`
3
J1105 P"VPAX) MIMS
$Cat
DEC U b 2001
' °S + `'tiS NOW
$3o4w2m
MORAQ&UINTA '
r
RECEIPT
DATE
/ � •e'
By
���
DATE FINALED
—oma
INSPE
-,
—
INSPECTION RECORD
OPERATION
DATE
,INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�_�� . �, _ S
Underground Ducts
Forms & Footings
Slab Grade
5=L . Z, _
Ducts
etum Air
Steel
��,� - _
Combustion Air
Roof Deck(
�� pZ
Exhaust Fans
O.K. to Wrap
�, _-ov
F.A.U.
Framing
ZI�� .. p�
Compressor
Insulation
Fireplace P.L.
Grills
Fireplace T.O.
n 7Z
_
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
l
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
2 - L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
®'
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- i2 _ L
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
A - a
Utility Notice (Gas)
_
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
y s
Low Voltage Wiring
Fixtures
Main Service
_
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
`� _(