SFD (9907-021)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. F�cp^Dat
1171
(,,Date7� 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.
(tom)` I have and will maintain workers' compensation insurance, as required by
S ction 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.
'i x' A T e fJh {l01 =fi{?C►T;'3
(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 te-bec^om subject to the
workers' compensation laws of Californip, and,agree that if Vshould become
subject to the wprkers' compensation pvisions of Section 700 of the Labor
Code, I h�l f9 Ciwith comply with tho e• provisions.
Date: l�� �6 ' Applicant
Warning: Failure to secure Workers Compensation coverage is unlawful nd
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 -rep esentatives of this City to enter upon
the above-mentioned property for Inspectiorupurrposs.
Vignature (Owner/Agent Date
v
BUILDING PERMIT PERMIT#
19°9t!`i<.er12t
DATE W ! VALUATION �H LOT TRACT y x y
IrJ ti.���.wt�iV,s�1dY I�f .� u
JOB SITE
APN
ADDRESS 0-1;i MON ANA
649-21:9-'W97
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PO AOX 1 110
79-t93 1WNC110 L-A QUH I'A DR.
LA k1 i1NI%x CA '41453
1_,A Q1e11N'i;A t'A. 9221+:3
USE OF PERMIT
:sji`401J. FAMiLl 1AV.8LL1N
Y001,. 7y3o PLAN (.1d -VK F.Ftr' ,tttidJUt "CION VUK ML;t,1'f`CE1T.1i
INSUANCI-, ( )!13 A&W, PLAN TYPE,
11Qt4.(,°14J1'A'T[0 1;-12.04,
JUSSUMNITI COSTOvtWNS.RIM.TION
OCRAW WE SUMMARY
r ONS'I`RU('11( tv Ali 1014)(M-41.1;-000
PT,At4 ("I -Ok- F1 3 (1 i .(t(tj1-d ist-•� f g W .71
ilil.:tHAMCoEJ' is 101.0po1;1000 I.36.5`•tf
L,LB-IR IS AL Flih 10.1-000-420-000
1Y1 t.1A.SB1W11PH 101-010-41". 0?
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�ISTR0MG
`IRAt71NG 17, F1:+ 101-000, 123-000 �4 1.00
wHkA°i'i2.iiC'i`i RE f,l 4� 2125-ifi3t 413-342 S h.€Yw.04
ART IN IJUBIAC I.,A( r� i - kh'SIC 7014AW-2::55- O S62BA d
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RECEIPT
DATE
BY i�
DATE FINALED
INSPECTOR
INSPECTION RE60RD
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
[ — _gab AZ?7c
Drywall - Int. Lath
Final I2 6—
BLOCKWALL APPROVALS
Final
Steel
I:rC/
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) l Gai
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:
1( OU{ �6t,►►. S
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