SFD (9907-040)LICENSED CONTRACTOR DECLARATION
:
C/), , '", I hereby affirm under penalty of, pe-rjury that I am, licensed under, provisions of '
H Chapter 9 (commencing with Sectiori 7000) of Division 3 of the Business and
CN .W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class • xp. Date
�` W •� •� u% t{'i"�•`t:
Z to e �r /� ` Signature`of Cont -etor"""`"�
O.� %
J U OWNER-BU.ILDE ECL-ARATION
UJ W :1 hereby affirm under penalty of perjury that 1 am'exempt from the Contractor's
'~ a_ License: Law for the following reason:
Z_ , ( ) 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). , ; r
(LOO I 'am exempt under Section '' _ B&P.C. for this reason
^.N Date Signature of Owner
O �< { -
WORKER'S'COMPENSATION DECLARATION
p Z I hereby* affirm ,under- penalty of, perjury one of the following declarations:
.p (') 1:have and will maintain a certificate of consent to self -insure for workers'
XA1'_'LL,
compensation; as'provi ed for ,by,Section 37*4 the Labor -Code, for the
Oco � :Q performance of the work for which this permit is issued.
Q`U (t) .1 have and will-, maintain workers' compensation insurance, as required by
Sec` ion.3700 of the Labor Code, for the performance of the work for which this
11' .� _H
permit is issued., M workers' 'compensation • insurance carrier & policy no. are:
Lo P Y P P Y
Carrier Policy No. .
• • 00 - iv'Y l+f•7! r"r h:n^o
., } _.r\: ,JA.LA'i.lid• G
(This section need not be. completed if the permit valuation is for $100.00 or less)'.
' O (,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-beeome subject to the
workers' compensation laws of Califo �a, and agree that if Nshould become.
subject to tj�e workers' compensation provisions of Section 3700 of the Labor
Code, s all f?rtt&ith comply with�those-provis'io
ate: 71&� Applicant �1 Y \ _
Warning: Failure to -secure Workers' Co(nYpensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up'to $100,000, in%
addition to the cost of compensation, damages as provided for in Section 3706
of the.Labor Code interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director'of Building and Safety
for a permit subject to the conditions and restrictions set forth "bn his
application.
1. Each person upon whose behalf this.application'is made & each person at
whose request and for whose benefit work is.perforrTed under or pursuant.to
any permit issued as a result of this applicaton agrees to,'*&, shall, indemnify
&ahold harmless the City of La Quinta; its officers, agents and employees:
2. Any permit issued as a result of this application becomes null and void if '
work is not commenced within 180 days from date of issuance of such' `
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City,''and State laws relating to the building
construction, and hereby authorize rep wresehta Ivt 's of this City to enter upon
the above-mentioned property�for inspection purses, "`
L.Signature (Owner/Agent) :2 { ' "` Date •�'
BUILDING PERMIT PERM T.#
- ,
DATE VALUATION LOT ' TRACT' y9 12
r
JOB SII E i:.` t
ADDRESS k�J�V �`61'.t�*kj _
APN . -tr
649••.�r��8-60
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'1 r+ nfd411' aLr[ T rNpIlRt;"'i"�,.�,.
,+/_.1/♦ }Vl L' .`
r�04'."t-r6• r,CA•i,Crrft_! J�,y,.r,l,/:,� I .
! f rf,ll \.�.i It i,. J 1 lb•%
t��d+ S►" ii.lca
74 295 �R�i'.t�f�tL;:T�tG ldt�%(UiT�1I MDR,
1a4 e Ultv'1°� A 92253
i;A. Q�ULfN ('A C.A.. 9 253
f7(`()7-11 1941 c,lii,,fj'7946
USE OF PERMIT
SINOX RAWLY DWELUK�A
SIM L i 80 P A1N MI. PC:$ilMT bOE8 NOT TRTC3:, -DF- s3L CK Iii?rt [>'L.
, It +0:5 L. 751, PLAN CHECK FUME iWDUO'10N FOR ivlum.Twix
�
3S�rtl, NCS OR S.ANIF P) AN't X?E.
t li,l+i1�'OiF:v(3 xI
,
s'�" i 580:oo my
1j1112,CIti %tib 3,x,1
0AkAt r VX!AR.€'QW1.' 69310 psi
Pe'KYy'T 'i'�-,i'r0 ."rbQ r ^r,? d'N1AI�:Tt)'RT!•nf'�1'1A,P
d6'1,A. 3I�R✓il.ldiYA. L,rALVt'Vr.Y :B A�.U4...6.6.'i,�SO ;
' ' 1/,'p *11•t+sA
- .CAp?f�:Y.Y F.6•tP
nn �(,. '�; }� ,g �0-iwt.p.Dlf
.)��11; RMI N tm M1i���.fl.���FAi'.�.Y
COMTRU FES • 1(3i; UUi�-4}ft-i)G4 $t 4U3.4►U
i Atld C; :C!c FEE,i 01..f}0f -d�i9- t f3 A7.47.97
14iE.•I;A,`�';fCAL 3-F; 3 btui;U'd'
E-JXCMUC11L T EE . ' , 10:9 • S304 410-000 x.245. y,
PLvkwlfgo nK 3.01-4)01?- 1 440 $18 3 01),
FS'S"R.<rDWCt.}VtO1'titlot -�}- dl: x}41 $16,4
GRAl INO :FM 1,01 »00 42.3 -OBD fiO
1141--kA8T•: LX)TIJR9 FVR 2254410.443 -It) $5,60.07.
ART TN,Pi1t31 TC, PLACFS f2ESV 70 i,4f14-255-OW 546129
' �:yy• 1R-� p i" / /� �� 3 I" 7 i�iY.. F +t"' • .,.L;,.-, 4. �A ��...,f 4eS:kY 1�.1��1..r.. 3.'dt`t {Lt�- .. �!Y Cr ��...».»
$;E Qp .ryT
9ii S •lid' .CI.C+SIS i"•R-ir-1".F1AL) L'L'd'S
$0,00-
71`01AL:II'>T RA f FEES DVE', NOW
twk—
RECEIPT,. ;,
DATE
BY t
DATE FINALED
INSPECTOR
INSPECTION RECORD
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
Gd
Exhaust Fans
O.K. to Wrap G
_ lV
F.A.U.
Framing
Insulation
Compressor
Vents
c�
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
—
Drywall - Int. Lath
<.(/
Final
1 ��
Final I— O
BLOCKWALL APPROVALS
Steel
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)
ELECTRICAL
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)
_
APPROVALS
GU
C26 t&W
COMMENTS: