0009-141 (BLCK)LICENSED CONTRACTOR:DECLARATION ,
Irhereby afflrm;under.penalty of perjury that 1 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
2i50 13 1� 2t
G;
Date �r/ere�Snj76,:)ture
of r f
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 EXEMPTPolicy No.
(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' compensatiVIprovisions of Section 700 the Labor
Code ash II forthwi ^comply with thos p ovislons. 1
Date. 4�+&t'cant
�t ��
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)
Y
BUILDING PERMIT PERMIT#
. }
DATE( / 4(� VALUATION 'LOT OM -141 TRACT"
JOB SITE./
APN
ADDRESS _V-6111 A,VKMA 0HFMG01N
- -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
R kMY WARONBE23
IZGACY HOMES
78-555 SAGUARO ROAD
78-533 SAGUARO ROAD
L�QLWA CA 93253
LAQUINTA CA 92253
—'
('I60)5644820 CB110
USE OAF PERMIT
r.3iM71AAL ]BURMING
�1
R
0�UPPLEME.NTAL. PERMIT TO 0= 415) 210 LF. 6-H O'AR N WALL
ONLY
6 FT. WALL 210.0 11F
v
ES'I'libdAI COST OF COWfMICTIOR
3g250M
PM'Yff FEE SU AR'Y §
�'
CONSTRUCTION FTE 301-000-418-000
SUP,-TMAL CON19I:I"CINMON AND PUN CHFtZK
$81.00
LEM PRE -PAM FEEZ
$0.00
'11yrA3a YT.R'AM HELPS PS DAM NOW
M 100
RECEIPT
DATE
BY f J)
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
sBUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts {
Forms & Footings
Ducts {
Slab Grade
Return Air I
Steel
Combustion Air {
Roof Deck
Exhaust Fans I
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
POOLS - SPAS
Steel {
Set Backs
Electric Bond !
Footings
Main Drain f
Bond Beam
Approval to Cover t
Equipment Location f
Underground Electric [
Underground PI . Test I
Final
Gas Piping I
PLUMBING APPROVALS
Gas Test {
Electric Final {
Waste Lines
Heater Final
• Water Piping
Plumbing Final f
Plumbing Top Out
Equipment Enclosure {
Shower Pans
O.K. for Finish Plaster !
'Sewer Lateral
Pool Cover {
Sewer Connection
Encapsulation {
Gas Piping
I
Gas Test
i
Appliances
I
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: