SFD (9907-036)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 .'bate
0 .1v 1,4
Date � � '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 oto 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:'
() I have and,will maintain a certificate of consent to self -insure for workers'
compensation, as provided' fo`r by Section 3700 of the Labor`Code, for the
performance of the work for which this permit is issued.
(,(,.)91 have and will maintain workers' compensation insurance, as required by
Seddon 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.
.51 f4iL�1YlJ V!tlS-{iVlf,r,P,�-a4
(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 sh uld become
..subject to the wff��rkers' compensation provisions,of�Section 3700 of the Labor
Code',-4sh 6klof�hWi h comply with t� se prrovlsrons.
Date: // Applicant
"W arning:•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 J706
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, indemnity
& 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"vold;if :f t
s , 94,
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. y
I certify that I have read this application and state that the above informatlontl;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 propert6or inspection purposes.
1-6
Vignature (Owner/Agent) / Date
BUILDING PERMIT PERMIT#
X499 -0I:36
DATE /� VALUATION LOT 70 TRACT
JOB SITE na»
ADDRESS w4`l^� 1 MONTANA �a�NA WAIT
APN �a i
649,14UJ07
OWNER
CONTRACTOR/DESIGNER/ENGINEER
f'u A01. ITIC A
79-295 RANCHO LA QU11WA DR..
JA QL1lNTA CA. .945'_4
1,A.QUIN TA (its 9.2253
USE OF PERMIT w
SNNGL PAAfii£:kr I WT-L,Uv s
8I: i3 ,., LOT 76 z?LAN'MUR - Pfi.�F3;(Vi•'i3' DOE'S NOT ,INCL.iJIX.r.',i,.(XX "ti< XLL
QK .OIDOL. '75'% PLAN C:ME";6 K Pr_ -1- .W0fJC"i':(0N. ORt W1.ITH."".LE
ISSUANCE OWSAW; PLAN'4'ifPR
?;. us,rom commuft. ION 4,"ut2,.00 SF
'
.Pc%i;Z.4:f pA.'iio 5w2:(tu &F.
t: iAtiJ\CiEiIGJVW10Wf 710,00 SF
''A,�i.'"6'rxiT.�•6�r•in.r^�o11.'M YOT'rrlArc�rar'��t'"11"oa1.Ai
ifoi7.fl lllY.f,.C]p5irl b-'1J1A3 'V& �.\.ISw,.9 fl.9.Y3J i. .i 1.'1J1.\
rxCe •Y41v �sta
✓ia.ap/lP.'9,JV
'PERMIT FEESUAM&RIr
C':%)NST1RL4"°I'I >N t'Il 101-fii3Om,41"00
IL,AN a-£�_;C'.€ 'rh7,3, 1;;ir4.I{)f -43-9-318, x33834
1` t .FifiiNYC�AL. r.'E Ii11-t oo-�42.1.�7ca S136.50
)<Li t",x421CA[. i 1Q;_-000420-000 ni6.11
P'LUUMING h4+1 101-000419-000
l•?'R'()N'Q �X0 -Doo7tt- ccfl0E0 14
UR-ADING FIX. 101 -000 -423 -NO 2Ei.t�O
LIVE' . `�`3`.I�L74"i lT=�& 1�FEt• .2'S -WO -443-34-2 96,000.00
AKf '1314 P LISL1,C ML.AC ISS -U,81113 . %0:1.000-2554900 $6213.47
"t1 N"ZIR CTIONtRDnPIANrIICK
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'1't?C.A.1,PERM TF.EFT.!.OVE:t" GVY
RECEIPT
DATE
BY % J'
DATE FINALED
INSPECTOR
l
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I
Underground Ducts
Forms & Footings
2--
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_ 0-c'
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Insulation
-
uj
Compressor
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 Pibg. 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
OX for Finish Plaster
.Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
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 _ CY6
Utility Notice (Perm)
COMMENTS: