0303-326 (RPL)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
Datef fl��er JdpSignatureofContractor
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.
p(6 I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of *e work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier STATS F f) Policy No. 07152
(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 ofCalifornia, 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.
e.Dae�/d r rF' s•:,�APPlicant�..»..-y' ;.•�. c'-��r�,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and.civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for insSection 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of -Building and Safety
for a permit subject to the conditions and restrictions set forth on his",•
application.
1. Each person upon whose behalf this application -is made & each person at i
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
&. hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.
the above -mentioned -property for inspection purposes. r
' s - ' /.�*: ' ! �; c.- -�, Date
Signature (Owner/Agent•) 4
,_Signa
Wit' ~ Y ,s & `' a✓ a:
BUILDING PERMIT PERMT#
DATE VALUATIONMLOT ��yy TRACT ry •y�
ADDRESS 4io'a°afi'air.11" JOB SITE
APN 73•''4 I
OWNER
CONTRACTOR / DESIGNER / ERTINEER
01
�.M't?Y�rsiLUADr:yR
77 -MA, SQg.T Rd CLUB „RIV 3p am137
/I-p9A 04G44�4
ATE VMY p
j 5
PALMDE€ERT CA 92211
PAtMDAMER'I' c& Y,2260
('Tei )77 ,,-82Z4 M.4f, :1137
USE OF PERMIT
WN GIZ FAW •Y Dwa1:.1k o
SWD • LOT S$ PILAN 3K P&RMIT 00I?S"NO'1 1•NCLU17i: F1LOCIC "1)11.14.1.1 S.
P004 IPA bR T113M1aWA:Y APP'Prl3,f93'H, 'g3% PLAN i.`•t•frVK FT_—.£
RMUC'1'ION DUX TO MUU IZ'LE I'S4.I.1110E, OF k AME PLAN TY1'Tt.
CUSTOM luOniMUCTION V41.00 OF
P(:?1xL.H PATIO 216.0.41 SF
WA.C1I MMFORT 518,00 U
ESM -TAM) COST OF CON MUMION.2364549.
y�.
C:i?1^€URUCT1ON FER 101w000-41$4,000 S1,WK00
PLAN CHF'.0 lis
DAL,C HANIVIIAL ME 101.000.14 :1+MO'o,.. s11~►*z5o
1�I:It:C.'P1:1C.A1,��.�' 1ii1-Ca�a'9•,���u-QOrti}�=�'- �ls�.t�p
PLTIIv BIND F&R. 1014C400-413-000 MIX
5'11aM40 MOTION IvF.E. RESID 101-000-241-000 sn.65
ORADINO fFIX 101.000 4V-0013 $15.00
01;9JE1.>iJPIM JIM-Pdi,€ T17ft" A405.00
ART IN PUBLIC V1I4}4«CE1, - =10L Z70-000-443-000
•a
8=x10TALCION`RUCAOXMI�D�•!a�ry:,}AMC
$4,2,
yIc�:z��+. �
.«.Ww..+,.w-.Y,���t .!'�. 1I�k.1..C"SF.C�•�'.F"eP:�i.Ev'�`.T2L7+b`�.
y27.25
Wil'. s'.p'
NOW
-,RA . D.E-p
RECEIPT
DATE.y 01
BY r
DA FIN LED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/2 -/ Z
Ducts
Slab Grade
Return Air '
Steel
Combustion Air
Roof Deck
--
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
/_,ir
Vents 7517, 7
Fireplace P.L._
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final ��
BLOCKWALL APPROVALS,
Final
POOLS -SPAS
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
,7
Neater Final
Water Piping
Plumbing Top Out
. -
Plumbing Final
Equipment Enclosure
Shower Pans_
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- -Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Al
Final
Utility Notice (Gas) �
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring s-2-(3
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors EEF/
Temp. Use of Power
Final-- ,
Utility Notice (Perm) A.1d
COMMENTS: