0012-138 (MECH)r
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
Flbfessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-•^�, 105 ' 5 C2L7 XI�
Date(� Signature of Contractor
J t�Y"u�-�'��''U"""
(ID al U.
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 formorkers'
compensation, as provided for by Section 37dO 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.
''ViL.Lai NOVA INS, C0 WC:11340262
(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 of California, and agree that if I should become
Subject to the workers' compensation provisions*of Section 3700 of the Eabor
Code, I shall orth ith comply wit o6 ppovlsionsV�/����„�, -
t<Date:i� "r�''�''Applicant ,,,f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $190,000', in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building.and Safety
for a permit subject 'to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person, at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued -as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the. City of La Quinta, its officers, agents and employees.
2. Any. permit issued as a result of this application becomes null and -void if
work is not commenced• within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and -State that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby 'authoriie,representatives of this City to enter upon
the above mentioned'prope y foriinspection p rposes
'Signature{Owner/Agent) Date
.-
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 9I TRACT
JOB SITE
.ADDRESS
APN
77-•'!.% AW_ :.VTR, 50
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA QUIlTiiC MMURY CLIT
f � ter ar7ri Fez � i .
77750 AM41* 50
49.91 J0141 DlT 920
LA QUDd;I`A CA 92253
PALM DEaW i CA, 92,160
2573
USE OF PERMIT
:i CILANIOA1:.,
r
RE1I)L,.A,,CF` JOUST➢" O S','':NT'FM'VJI 11(3�:,20 ' CYN CH11,11,9 s, tmv.A.Lz
90' O 0 MWE, RRI.a%]CATV. EtAti:`TRIt'.AL, 06811.L:, UI.RI<`D.
VAIIALINflON 110,00P,t1Y•e LS
F
. �i���xx+..IA.�. COST {; F {„ �i1�TG";��€��MON
110,4:�i30A$
yjq, y�,g;3�i y •g, �1 f ,�.•7�.
S. JC.RLI%�K ,.9V9.L,'E IJF6J.la/&M1F] Al 1" .
-MEC'1•I113 CAL FS.E, a 01 _000421.000 $82,30
IBIXC` RICA.i'� FEE j Ji 000
PI.MATIT 3O FER 101-000h419.000
" r
DEC 18 20GJ
Lr%
A,WJD Px..WQ1HECK
$160.50
IT`S' PRE -PAW IF.
Sa.00
:t' .pair 'fCCYsi .3 'STY L'314,T' CYt
,`;X .5i1
RECEIPT
DATE
_:
BY'j ?
DAT[ At EpD
INSPECTOR
(/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K.to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
.
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
/l 4_�Ir_, 1
--I COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
. Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. .
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm)
f---------- -. --7 ---------------
AC VISCO"CT I
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AG PISCCII:GT
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480-120/ 208 v
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120
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_ _ _ EXIST_ FEDERB _ I I j
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U EXISTM TRANBEORMl�R TO MAIN PANE
j I MAN PANEL
GROM- MI). MAIN PANEL Gd�dDED. TO.
I j -i4hiP .
I
NEA$MY WATER OR GA6.PliE..
�: i .26W 130 v.
-
..1J ALL. fNT'CARRYDdG
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CONDUCTORS. SHALL BE..':
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1 1::PN 4tU .
I POW ` 120.
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12b AMP�a31 I
PANELS.. f
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I B' AMP- 3 PN
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230 v
1 I0 CONY PLUG
H&H Air Conditioning bleating
----
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74-991 Joni Dr., #20
FWm Desert, CA 92260
AC DISCONNECT
bo
v i acc �
ELECTRIOAL. f LINE DAGAlll1'
A K INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
•.--•-CLANS AND-JOB-CM—ARf NOT ON �—.
C fTY_ C F-LA� INTA
THE SITE FOR A 'SCHEDUIED
BUILDING &SAFETY DEPT.
INSPECTION.
NO EXCEPTIONS !.
APPROVED
— �- .._....._
• .._.�_�.
FOR CONSTRUCTION
.NOTE.:
1 WHERE. (N) SLAB
.� .•
IS: P.OURE: I-T SHA�.L E f�JNIMUM 4" TH1CK(U:N.0) WITH
- •
DATE BY
.,
#3 18" o c EACH WAY OVER 4 BASE MATERIAL
-PROVIDE VISQUEEN WHERE REQUIRED BY: THE. 'AROHiTECT OR AS REQ;IJIRED
BY. THE FLOOR 'MATERIAL.