SFD (9907-033)LICENSED CONTRACTOR DECLARATION
f hereby affirm under penalty of perjury that 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
h f
c /4iy, ! i,115i
7 ��.
ate �} fir. Signature of Contractor
OWNER -BUILDER DECLARATION'
I hereby affirm under penalty of perjury.thatil: am exempt from the Contractor's
License Law for the following reason: y ,
( ) I, _as ,owner of the property, or my employees with wages astheir 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)
O 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:
O I ha4a96 will maintain a certificate of consent to self -insure for workers'
compensation,'as provided for ;by ;Section 3700`6f the Labor,Code, for the
performance offthe 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.
aT,li,.i'iND �ii�a-rio334 ,
.(This section need not be completed if the permit valuation is for $100.00 or less).
O 1 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 ag ewe-fPrat� if I should become
subject to theyvorkers' compensation,p` io s of Section 3700.of-the"6abor'
Code •I s II j6 ah comply with those provisions.
4a�teyi ,/ ode .1 Is/% Applicant�)
./'Warning: Failure to secure Workers' Compens-ation 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 r p senta ivies of this •city to. enter upon
thefabove mentioned property for'�ection purposes
C �_ .N,. /
k6gnature (Owner/Agent) C.1 o Date
BUILDING PERMIT PERM T#
99
DATE h VALUATION LOT TRACT
JOB SITE - '•
ADDRESS
r
APN -
0;44 ��• 1fp@ 047 ,
OWNER . -
CONTRACTOR / DESIGNER / ENGINEER
TPIDE T�;�� 110P;tS0 y
I
�g�e�rn.�.� f.':��dS�''� JC:' ���I
PO 90.1.1 :1`:16 '
.79495 RA140:40 LA qJ NTA LR_
LA.. Wi'NTA. CA 92',A53
A. QUiNMA, CA 92,2 53
iiii0b71i-194i C.JTwi .
R
USE OF PERMIT
$ NG E FA,MRA DWO-7 °°'".ri,,3NG a
�'
V, 0 , LOT 13 PiAN N P;GRMU , 003 NOT YNCLUDE BLOCK WALL
�:7fiPUc�Li 75fPLAN CF6C:F6;IWUCT10.'ftR_1tLffIPLS
1
#SSfJAN6%0tiAtu.3L+NT 101:1,.
COSTOiV c'ONSRUC Ir'.iurr 4.213 00 sr
r
POI .CFTI A1.10
GAMCiI CARPOR'
,,y+�Jq{ dl.,Y,6. €1.'off��.'.YT..4:+,D COST l.f10ii.'ar..�J CTL Et.Ot! �
� ,�SA�.PtY.um-
tty� `.TTaa,,pp��•• •y,�� .��
ADds1iMIT A' E t7V Si'PMAR Y
.
CC-)N5TRUCs71014 FEE 101.060-418- $1.521.$0,
pr,. N Q7 rVEM,
'f4t�e�,');1'ANICt1�.3 1®�"-4U0'*tis�^�)s)U $i�)G, W
•
PIXXTR(CAL 401-000-420-000 $246.13
PLUMBINO F E 101. 000-419-%)O $205.Ot3
STRONG MOTION Ful - 'REISTO 1.01.000-241-000
G"YING FiM,10! 000�4`l f10ti 2o.or
1wkA. 5'Z`C4:1}4mm" 225 -NO -443-34-2 $6.()0.00
AI2'3' 'i?N PV8Lt:C •1 LACB$ w AESIr 701-000-255-000
�: g*{{{{�.�.�y,�t�`� !`��a�e,a:�,�►;:fi;�t1v��:t ���� x3's�I�:+:'tv�vV
��,1332A)�
/11Q/y A
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
cicol
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
_ G !if!
Exhaust Fans
O.K. to Wrap
1, _
F.A.U.
Framing
Compressor
InsulationVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
U
Drywall - Int. Lath
Cd
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
I I
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
COMMENTS:
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)