0108-247 (COMM)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 Exp. Date
Xate(• Signature of Contractor
OWNER -BUILDER DECLARATIO
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).
( ) 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 AMERIC:aA.N CAW AL Policy No. VIC'2,92:1036W
(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 should become
subject to the .workers' compensation provisions of Sieption 3700 of the Labor
Code, I shall forthwith comply with those pfo ision
D!ate: `�Ilf"r`# Applicant 1 4 I + - ; {
ff .
Warning: Failure to secure Workers' Comperfisation 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 harmles's 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 inspectiomVr�iklfi"
rposes. '
y �1Signature (Owner/Agent)./1� 0 r� I' Date &7 `
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �B.Sf�i TRACT
�9A147{.W{Sli•�lR1' '
JOB SITE
APN
ADDRESS ).A .M0 ��.�17s�6�
f%.b��D!°�- �
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Oi��:��:Ck;L1,,A'i�''A1:,I,�„'3C ��:.C���:iCP1�;As� d�: a3?�..
,�:�,`�tT�:(��,'�.�,�.��k�.l�"'�►1.• �'�:��:iG:%`i
`77-8,6S W AVOr AMOEDi1M
: 0472 M0`.�•�' )BAY.DRIVEMU Ifo
LA QT i1.MA
LAM FORMT CA. .92630
(9495)4.04990 C;S110
USE OF PERMIT
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et3Ct 1r. il2vAd}i1,3 d LT' ➢31 �'OA� (t51J16: ,�1(JPdS RACIVITYWi t1+3CatdOPAi.,►A V
TOWER 62 LP,, W RINCE PER CUD' 20"-014
2 _3F
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9y'tAs, ({{ rt/39
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6 FT. WOOD Fralce 63,00 LF
VAJIUA.TION Ls
XMIX&IRD (""OST 03 CON61R'U'C170N •
694= 100
PLAN CHECK FEE 101-000-439-3113 SPAM
4 .�P.CFf�`1I9fC;'6,C iii �; 101-000-421-000
ELECTRWAL DAZE 10? -000.420-000
a 'itiC3twCt.MOT1010 PZE - COMM' 100 -01007 -2e11 -NO
ia£°;\fI?'-01FER.:MPACT FEE
Cf i1`tt' !?'lJ811C 1'DAM - COM? 270.000-145.000 $24,33
C0NSTItUC ID14 PEZ 103 -000-418-0051 �go.OG
;SUB-TO'1'AT C'+ . rr. ,...fix" :li 'MD P1... D CHECK
$599.89
lr"D 111213 D NOW
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$59%88
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RECEIPT =
BY
DATE FINALED
INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings _ G�,D� . �l ►,
Slab Grade jB'�
Underground Ducts
Ducts .
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace.T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final°
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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 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) �(
COMMENTS: