0211-006 (PLBG)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.. Clayysppss i Exp. Date y pp.yy
./Date �� "/ Signature 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 EXEMPT Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(y)� I certify that in the performance of the work for which this permit is issued,.
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwit44 c�omply with those provisions.`
Date: /fw �J " � 'Applicant
Warning: Failure to secure Workers' Compensation coverage is 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
thefabove-mentioned property for inspectionpurposepurpose .
ivSlgnature (Owner/Agent) /' �G�i'.�! Vii'; ! Date/J L
BUILDING PERMIT PERMIT#
g! 4`1
DATE VALUATION LOT TRACT
JOB SITE; ' !
APN
w� d
ADDRESS.
OWNER
CONTRACTOR/DESIGNER/EN (NEER
” WUJI A DALMY
'MAMAS M.MYI 3(rLJl v3nt i C:t a ,' %1
54 604 7 +}i1EMN.� 911
95 324 OLX 1, rid. F
:. Qtgw. r'fia CA 922S3
Call.. 02253
CY60 71A915 CR1G3LH 24N
USE OF PERMIT
fNIS ',b't.I..L 50 L'M MIN i`I&S LJ'NF I♦`ROM "FIXIS'j'1NCi 31r'U23 ON ROOFTO
HIENGA..w CJl:A1 TOP IN KiTCHIDr `�'iJ1'e.APPRMJD DRAMNO),
ESPITKA3113) ','0 j' OF 4°'ONSTRU MI 01?
MOM)
PERMIT 1,17M MhfnkRy
PUMB)"HO Furl 101.000.419.000
t .
N� i 1f
CITY OF LA yule �,
FINAN0
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911'1t.Tr't1"'i-.C;ON_ a ir°'f"T'IONYlA91)PLAN CRIEC. ;.
TOTA
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RECEIPT
DATE
BY.
r
I D INA ✓
SPECTOR
/ /
INSPECTION RECORD
1 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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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
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
L
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 Notizie (Perm)
November 4, 2002
City of La Quinta, Department of Building & Safety
78-495 Calle Tampico
La Quinta, California 92253
Drawing for gas piping for:
Mr. and Mrs. William Dalbey
54-604 Inverness
La Quinta, California 922
Thomas M. Flynn - Plumbing Contractor
State Contractors License #355881
(760) 7714915
New Gas Range: Fisher Paykal Model #GC -901
Total BTU's = 34,000 or 31 Cubic Feet/ Hour
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS!
CITY OF LA QUINTA
BUILDING & SAFETY DEPTi,
APPROVED
FOR CONSTRUCTION
DAT1 By
Total developed length of gas run = Fifty (50) lineal feet. off 44 C T f
200t CA%_tFaQj4cq
Pursuant to the ;44for-m Plumbing Code, Table 12-3, the maximum delivery capacity of cubic
feet per hour of 1/2" IPS pipe X 50 feet, carrying natural gas of .60 specific gravity based on
pressure drop of .5 inch water column is seventy-three (73) cubic feet/ hr. or 80,300 BTU's.
e.1 /�� to