0111-234 (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
67 4 . 11f �" 7d"i 141(
Date! Signature of Contractors
OWNER -BUILDER DECLARATION t
I hereby affirm under penalty of perjury that, l am exempt from the Contractor's
License Law for the following reason: I '
( ) 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 STAYF'FUNL� Policy No 11Q�-DtJdl?��3�
(.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,
p l shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California and agree that.-rfplohould become
subject to the workers' compensation provisigns of Section 3700 of the Labor
Code, I shat};forthwith comply with those provisions:`
Date: k, Applicants % ' '
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 fo
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 perrtnit'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 that1he above information is.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize •representTtives of this City to enter upon -
the above-mentioned propFertyJo.qspection purposes %=
Signature (Owner/Agent) - 'r ( ✓� Date
BUILDING PERMIT • PERMIT#
DATE VALUATION LOT 0111-4.14 TRACT
j G 'W •�CDt.S�'s,1ti� ZSR 7•:i,
JOB SITE
APN
ADDRESS 491,-3i.5'S1S1:**#A F5rr1.MLWL
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TO ;t7c?1M T D.EVW,(Yf>;Mt,T1
SPAPM CONSTRUCTION
X"4��'�•+ X 1716 '
79-295 RMC1i0QCT-.N'EADIX :r
IA OVINITA CA 9221.3
LA QW91"A rti 92253 '.
(760)771 r 1941 C Uft, 2996
Ry�MIT
USE OF PtEE�C
h err Yh 7 Al
UXA
3W - LOT rs7lrLAN irk. P&1 IAT W S WOT ),XCLU1)X i; 3t;,O.CX•3ia%ALU,
P0014 SPA OR DPjVrt"WAY APPROACH,
SzC3TCC11FPdb."d"1 ► 235� OQ SY
f: ARAQVICART'G#RT 4470,00 Or
,TfOF COMMIZU471noxi
'g
7A0,117A0
7ESIMAI.
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,id��%�Ca",7Lw0.5.,.LL 171.P.1Vd.IV,Y�TiAd .
C"ONUMLtC1'l;CYN 10)-000-4.1&000 tl113100
PW4 CRECIC 17FE, 101440-439418 40-439418 343424
MV -M NICAL1`*t 81.30,150
ZX CUICAL PVF4, .101-000-42Q�•0i1t"A $189.34
Pl.afNOM FiM 101.000-41,9-000
SnTyltAct��'f.+�Fit,�p+tM(YYION FEE, d PIMID 11101 •t00,0241-�(yA)0
®32A.t0111
,
0.76a.1.,t*l.t+I CVa,81":.5�. 1i,7�"�74!'ea"'•�{ra��\T. Li� i2F�.Sxo
'
.'0ZVn,0P ' IMPACT ISX Do
ART 1W PU11.1,1C PI.ACTS - KOOr 2iO�00044. 5 -tom �10p,x9
"a$)WE;Cd':' .t,.° N AND P AN C".'ff.T YN,
$3,02.0
' DEC 06 2001.
RECE 11 ��gg �qq^^�� cXe
By'.
DATE FINALED
INSPECVA
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
rG
Set Backs
2% - Z a
Underground Ducts
Forms & Footings
—/$ _Z
Ducts _
Slab Grade
zC', 07
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
/j _ c
F.A.U.
Framing
—��
Compressor —_
Insulation
Vents _
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
c
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
��`®y `S
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 APPROVALS
Gas Test
Waste Lines
_
�Q —�
Electric Final
Heater Final
Water Piping
_ _
1�
Plumbing Final
Plumbing Top Out
r---
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
—/®' - Z
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
�d •' 7'
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)
p i