0101-073 (BLDG)LICFV!.'8ED'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 , Exp. Date
ezy
Date Sigriature of Contractor �+"rt 7e
f OWNER -BUILDER DECLARATION.
v 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: •
�(r) 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).. .
O I am exempt under Section ' ' B&P.C. Yfor this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:.
O 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 workifdr 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.
STATE FUND,
(This section need not be completed`if the permit valuation is for $100.00.orrless).
O 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 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shajeforthitith comply with those provlslon`s. s
.Date: -s Applicant a''a ' =
Warning: 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 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes r a
Signature (Owner/Agent) +°I ��" ��� ,r •�� Date' 'w
BUILDING PERMIT PERM T#
DATE VALUATION LOT' !' 0��1:� tt �.�i TRACT
JOB SITE,
APN 4
1
ADDRESS
441895 ti'�'4�KNIDA MO:t T ��':t.:�+".Y A
OWNER
CONTRACTOR/DESIGNER/EN (NEER
�r52i& M— MEs"com
opTNE.- " b, fJ'ow:L oribiq co
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1240YO�tflni,���9,.WAa
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��.i. •l,.ch? .1�i.!S? �.r-:,N 92833
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fY,A
J•aA.iY.P'AUA CA :.'�167�l •.
+CBU
{;3.1 ilj 94-1472 , 4695 '
USE OF PERMIT
t•6111..(�•J �yPT.O'IAt�
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PiqNID.hRD mNI .AT
4 I i • �r j.
W4YyC�
LF. 6111 Jr,CITY
APPROVED A844ONLY,MUOT "€ftY WITH'COMM, DEVELOPMENT
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.CCi}�L9�� 1 .�x7TJ .��.4.fV ,'iFJ S • .
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NM
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MIMATED C2i'l�r"T q CC�:�if5d 'i f ;u�'IiQ�l
41,000RO ,
�,
O;ONSTRUCTION FRI
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.. pyo •o
:• tID1Ti ITA'LCOMtZCAJA DaL'CAIRCw
$6,33.00
VrC,Y rMS PR-PAIn.yy+RI}}
TWALFE'RINUT FUS OEM NOW
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'L
RECEIPT
DATEr( f1
BYE f'
DATE FINALED
INSPECTOR . .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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 J
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
Set Backsl
Footings
APPROVALS
_o/ 6 z
!
steel
Electric Bond
Main Drain
Bond Beam
—� _ O C S�
Approval to Cover
Equipment Location
i_
Final �9 Q
3 i i
PLUMBING AR ROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Waste Lines fHeater
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)
^�rO&#
Apio
11 wmi
VAT I
I? wla 1.7
CITY OF LA QUINT, j A
BUILDING & SAFETY DEPT RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
APPROVED PIANS AND !OB CARO ARE NOT ON �i� �
FOR CONSTRUCTION THE SITE FOR A SCHEDULED 1i� `b'�r� ���'��.
INSPECTION. \(,
DATE l S o7 BY NO EXCEPTIONS!
1 J I ; it 1 - i Ii�
.I I S I
j,
IWIL I BE HARED IV THE APPRO 0
PLA S A�11) JOB CARD ARE 1.110T N
ITH SITE HOR, A StHIEDUL D72
lNS ECTION.
NO �?(Uitloqs!
i + ! � I
Dt-!l
�I .j I I I � i
01T* dF LA'Q IN -VA
BUILDING & SAF:ETY DSP
Off/
CO;N S'TRucLriQN
DATE I B Y�--
1! Will 0
00
'H.-- o
A �..
�Lf d
t , Ty I I T7
,;.=;-,: i ;. ;��0;I0N FEE OF $30 CITY OF LA•QUINTA
WILL BE 1-WRGED IF THE APPROVED BUILDING &SAFETY DEPT.
PLANS AND )OB CARD ARE NOT ON APPROVED
T _ _L_ THE SITE FOR A SCHEDULED
INSPECTION. FOR CONSTRUCTION
NO EXCEPTIONS! - r
DATE O BY
a'v A� . �"