0209-170 (RER)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
73319 13 MC /= 313 *3
/ate r Signature of Contractor—L/ S_
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). ,
( ) 1, 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
perfo mance of the work for which this permit Is Issued.
( 71 have and will maintain workers' compensation insurance, as required by
Sehon 37001'of the Labor Code, for the performance of the work for which this
permit Is Issued. My workers' compensation insurance carrier & policy no. are:
Caller STATE nMD Policy No. 04601UNIT0099915
(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 thq workers' compensation provisions of Section ?700 of the Labor
Code, I sha forth pith comply with those provision
Date: Y,6 ./Z i gAPPlicant
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
additlon to the cost of compensation, damages,as provided for in Section, 1706
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 persoh it.
whose request and for whose benefit work is performedsuhder or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnifli
& 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 sudh
permit, or cessation of work for 180 days will subject permit to cancellatioh.
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 jnspe tion. ' urposes. r
Signature (Owner/Agent) _ Date>�-
�' t,4
BUILDING PERMIT
OW -170
DATE % VALUATION LOT TRACT
� �1Q,t>ai<x�v
�2y Zr ,
JOB ITE
ADDRESS + IU J)G.4INVIS; PM
APN _ L
OWNER
CONTRACTOR/DESIGNER/EN (NEER
11GA WE.4r R.1v'8lDMIAL HOWOWIMS ..
S Dom: MA& PAC YKI GWE.RAL C13N11? kC' )
P,U. BOX Mo
25;-3 3 S(Y(TJU COAX HIGHWAY MY, 250
ISA QT -T"1 -A. CA 92253
CAi7T_)" BYTHE ;N`F.,A CA 92007
(760')635-1010 K'E,'f i# 582'.4
USE OF PERMIT
GlE~'Z,1MAL .Ly'C)71DNIG
SEISMIC RK17RO-PIT; 81,DO. 4: 54.349,1 `3=59.
VALUATION 1QQ(15.93i1 C,21
'F.S,"I91HV17EIA C(Xr'.t' 01r is 1Nf>°xh''[S;:"1; Off
3.00 ,0.00
CONETRUt::`. ON ; FY, ) 01. -(71')00 18.000 $117,90
TR.ONO KEE. - PEZ1.0 101-000-241 • (1{If1 �1,U11
.3
-t SMIXIMO.K AND PLAN CHECK
$118.00
SEP 2 f 2002 IMS PRE -PAM KMV
, $0.00
l� ;AL L Plad IJ.'I' VEES DUY, NO'W
$11%00
CITY OF LA QUINTA
FINANCE DEPT.
M.EIPT
DATE
BFw_^-�
DA AL
PECTOR
INSPECTION RECORD
.TA
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
BLOCKWALL APPROVALS
steel POOLS -SPAS
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
Encapsulat'.on
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main ServiceCD
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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