0402-134 (MISC)�. LICENSED CONTRACTOR DECLARATION
I }iefeb 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
s / �r�'
Date ! 1 -��• aSignature 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
•(1).. Icertify 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. f•
,,Date:-,/ Applicant F
Vl4✓ f s� L1!
, x , ="
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided.for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
'Signature (Owner/Agent)`/'' • f' • '`� Date Z, �7�"•✓�
BUILDING PERMIT PERMIT04C
134
DATE (Y.41 2/200 VALUATION WSW .0. LOT TRACT
JOB SITE ADDRESS ;� rdri� ��aielaci�M'1SS a(., P.'L,. 0
APN »
OWNER
CONTRACTOR/DESIGNER/EN (NEER
81-100 AV WC11'? � 3
7 2,320 AddsMt;f FAG" IMMG ROAD
LA (+31..i's�1�f'A C k 9225:
1710UML�ti►1?At MB CA, 92276
I-
,760)340-3992 C
USE OF PERMIT
SI'EMI AI. 424SPLI C IOAf FOR '1'ZHT &. ZI 7i C9TRiC:1 1, A.T SPECI.A1, EVYI d9 AT.
g' iib3&.>!a-WA'Y°, WLET'psl1.'3O APPROVED PLAN
VA.L17A 101"i 414".0,00 LS
E'YT&.UY.LA71 Y: D te9.i'A7.`. COO C O. -MIS S4$� .�,r.7.JO
.P.Y21_ T' FEE IwMMARtY
3P;"01'A,L, WSPEC JON 101-000.4.23-000 $100,00
D p D
FEB 13 2004
CITY OF LA OUIXTA
FINM4CE. DEPT-
Mi'-TOrfAl, CO).Y\72&'ilJl, rION dtllJCn1ACY:CK
.EJcyiL,;PA1D 'wJSC'
t ,f4^��Vho°p.7ut+t
RECEIPT
DATEBY
r
DATE FI LED
INSP OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
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 Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
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 I I
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
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:
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of La
City Qu] rata ,
Building at Safety Division
P.O. Box 1504, 78-495 Calle Tampico
.La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
z-/
Project Address: _ t Lt—y, c., 0 CLjp(3 ply
A. P. Number C -mss
Legal Description:
Contractor. CLPSk L
Address: -,,Z-,g2.0 M � T
4 0wner's Name:
Addrcss: - Uo �3
Ciry, ST. Zip: Lp Qv ► �TPc UAc 22 63
f Telephone:
Project Description:
City, ST, Zip: -�- , Cwt -ZZ-7,.
Telephone: ,(o
N T �' T1 tiliv tiIY�C�� -
State Lic. # .ff
City Lic. #: 0�51qjf
Arch., Engr., Designer.
3O O p M
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Construction TYPe: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq• FL: �OQ(� # Stories: #Units:
Name of Contact Person: Co
Telephone # of Contact Person: U( -OJ -1-1--7+0 V
stimated Value of Project:
APPLICANT:
DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Ree'd
TRACKING
PER;IIIT FEES
Plan Sets
Plan Check submitted
2 //
Item
Amount
Structural Cala.
Reviewed. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calc.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Niechanical
Grading plan
Y' Review, ready for correctionslissue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
3" Review, readv for correctionsltssne
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
LJ
Total Permit Fees
M