0111-236 (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 Exr). Date
✓F
Date / ,fit fL} Signature�of Contractor t •' f
OWN ER -B UI LDER'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's
compensation, will do the work, and the structure is not intended or offered for .
sale (Sec. 7044, Business & Profes^ionals Code).
( ) ,1, 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.0 for this reason .
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
['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:
Cafrier ,, t,, b , 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' compensalion laws of California, and agree that ifdl�'§hould become
subject to they4orkers' compen sation'pro9isions of Section 37.00,of the Labor
Code, I shallfforthwith comply with those prpisions-e'
Date: f :_ ' Applicant/ ' j {
Warning: Failure to secure Workers' Compensation coverage I .:unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, Ip
addition'to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit, subject to the conditions and restrictions set forth on his.
application.
1. Each person upon whose behalf this application is made & each person at,
whose request and for whose benefit work is performed under or pursuant to
any permit issued -as a result of this applicaton agrees to, & shall, indemnify '
& hold harmless the City of La Quinta, its officers, agents and employees.
.2. Any permit issued as a result of this application becomes' null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180•days will subject permit to cancellation.
I certify that I have read this. application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.
the above-mentioned propity for,inspection purposes
Signature (Owner/Agent) -�I 'k Date2
BUILDING PERMIT PERMT#
DATE / /VALUATION LOT 0• TRACT
r �� e r. 1,7.10 F a j. ..
JOB SITE
ADDRESS ' 2...75 VFYC.i`.R 1[:.RNEU4A
APN
649—�.Oi -ij 0
OWNER
CONTRACTOR / DESIGNER / EN (NEER
IWAR# S C{,33�"wa.R U'CTiow,
'P0. BOX, 1'716
79.295 MOM(-) LN Cs'l'i aA D
.VA QUWA— C& 9.2253
.%tib-JDF A CA 92253
(160)771.1941. a3l'o 296
USE OF PERMIT
£fI'LE1p"IL�I D1011-1.3 .IM
'
V.P •. 1ZT A.9111,A.N ZZ PERMIT i OFS: NOT rNF+;:1..U15,'8WC K WALLS,
POOL, VWX Oft DrUVVIAV APPROACH
CUSTOM CalflYfRISCATION 1,92.1,00 3F
1?LiRCHN 3°Y'IO is34.€ik3 Sid
GABA lr!'C; I P01' T
PERW C EVE SUMMARY
CO sY'R1.14"1',i1L?N FEIV, �2�OOL4$€ -ElfiO i�e33.U�
PIAN GHW '&+; t 39'�C f1eJ-�t3 X31 �i $ ii. 4
115M.A IC.AL PEP. 101-000-42).-.000
PIA0401140 Irct Z 101 -000-419-000
101-000.241,000
(iUADY96 !MIX 101-,000-423-000 3'20:00
DWE1A)PEifi.1MPACT FEY $1,90?.tw
W `3'1;1 L 0,111113 'k`RZY T1.1 14 ,A%?7Dy P��+1���P.tt4���t[;� �{{T��ppt"`��T��C
$3,4��{{avv2.0aa30
pp;�pp��•]]
lE'.�.�'�,t'1.F PES DUR, P'f>'4?4r
33,992.03
6
DEC 01
,I
WYOFLAQUINTA
•RECEIPT
DATE ' /° °
BY
DATE F NALED
INSPECTO
' sr
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
y-/8- Z-
Underground Ducts
Forms & Footings
.y -/$ - Z
Ducts
-
Slab Grade
</ -/.E,; - Z
Return Air
Steel
y=/ W -y
Combustion Air
Roof Deck
6 //-Z
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
��0 -per
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
I
Final
POOLS - SPAS
9/
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 APPROVALS
Gas Test
Electric Final
_
Waste Lines P
—
Heater Final
Water Piping
-7 /% _ _
/' /
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Sr- L ��
Encapsulation
Gas Piping
Gas Test
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)