SFD (9907-031)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. Clas$ a.a 674074^ 13ii
Date Signature of Contract
OWNER -BUILDER DECLAti JA O
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: ,
( ) 1, 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
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.
STAIII,!,' FUND.0Y6-{3Q073"a3
(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�tha't if I � hould become
subject to the workers' compensation pvisions,of Section 3700 of the Labor'
Code, I shAll fo,bwith comply with those provisions.
ate. l !�'� Applicant
Warning: Failure to secure Workers'((Compen idn coverage is unlaw� I and
shall subject an employer to criminal penalties and civil fines up to $100y000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on. his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all Citty ,,and -State laws relating to the building
construction, and,hef@by authori representatives of this City to enter upon
thabove-mentioned property for inspection purpos s. /
ignature (Owner/Agent,_ i/ Date % '
BUILDING PERMIT PERMIT#
�vi3%41,x$.
DATE VALUATION .1,388'30 LOT TRACT 289)1,2
h
JOB SITE
ADDRESS 49-4:9TMlfNl'J.ANA WAIT'.'
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1`U t�.i.Sf?it'1 11:�:'k I.C)FA�a.i I�1'11yt14Z.#S
COAl;'1iZ3JC"1:Ji�r .' .
PO 1'YX1716 ,
19-295 RANCHO LA QUINITA DX.
LA QUINTA. CA
LA QUTAfTA. CA 92253
t
(70)771-1.901 C$L# 2,06
USE OF PERMIT
SNIOLF. <FNILY OWELUNG
S.i:D - LC)'1. 71' 'L'L.AN M5 �-1`1071bi(T 3i]FS L'dC>3. 1lVC .i3'Diw,331L Gh �i L
Ot'1.POOL. 79' o PLAN Ck{#:C.K FE-, -,Rr! : Ur—"ri0iv FOR MU-1#fii'1 IPLE
(SSUANCid O(2. SAME 1PLAN `tYf E.
Cd;MINI CONSTTiUcMON 4,2=13.00 SIS
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0ARAMCARPO2t'1' '/ltl.i;0 fiE'
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.✓�A i MYID.�Yff
CONS'1'RU ("ION "FFF. 101-000-418-000
PJAIN CHECK 1Q8.73
NAIC;1�"zMICAL FEE 101-000-421.000 �.i36:S0
101 -M -420 -ani
P 1JM'8PgG FM— 101-00041.9-000 �biiS.00
ST. guiC? i Tsw1IV 9'F? . fr'3�J.O .413 •Q(1()41-C10fi,w35, tc!
CLQA1l 1ZtiC1 1:s 101-000.423-,4.300 %Z0.00
>iW-RA103rRUC7rVRE FRF 225.000.443342 V1,00.00
\A'(' T.N PUBLIC PL A.CFS - RE&Sll.. 701-000-2554300
SUB-TC9TAII, C;O ',107iZUGON ANTYI)�»11r:,A,ryN C13.C'`r?�
$9,102:05
LESS SRE-Z MElI F.tISti
$0.00
1.:. z.
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IWO
RECEIPT
DATE
BY % .if
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Z-
Ducts
Slat: GradeReturnAir
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
!i(/
Compressor
Insulation
• 2-7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Part] Wall Firewall
Exterior Lath
Drywall - Int. Lath
(�
Final —
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Sacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
— Q
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<<v
Appliances
Final
Final
Utility Notice (Gas) —
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 00
Wily Notice (Perm)
COMMENTS: