SFD (0111-168)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;' ,
foX717 13.1 X' %Inx
Date. �°�� Signature of Coni, to+ir' ,. t'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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). f .
1, -.as owner of the property, am exclusively contracting with `licensed
,contractors to construct the project (Sec. 7044, Business & Professionals
O I am exempt under Section. B&P.C. for this reason
Data ` Signature of Owner
:WORKER'S COMPENSATION DECLARATION
I. hereby affirm under',penalty of perjury, one of the following declarations:
(
J. I have•and will maintain a certificate of consent to self -insure for workers'
Compensation,. asprovided for'by Section 3700 of the Labor'Code, for the
performance of the work for which this permit is issued.
(.) 1 'haye 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, TATAD
;(This,section need not be completed if the permit valuation is for $100.00 or less).
( ).'I ce0ify 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 Califofrna,, 'and agree that if I should become
'subject to the workers' compensation provisidns of Section 3700 of the Labor
,Code, I shall fortwith comply with those provisions.
Dated Applicantl'
Warning: Failure -to secureWorkers',Compensatlon'�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 B iikng!and Safety
for.,a permit subject to the conditions and restrictions set forth 'on
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 authowae representatives of this City to enter upon
the above-mentioned propertyfor il��spectibn purposes'
Signature (Owner/AnentDater
PERMIT# e
BUILDING PERMIT
DATE VALUATION LOTTRACT '
JOB'rSITE
APN
ADDRESS , .. Aft, tikV"�DY1.l<rI?YVF.Iljl��
OWNER ��
CONTRACTOR/DESIGNER/EN INEER ;
`�x91��' ��:'V.(s��bJ�"A3'T
'�-�.AT�:e:..�f �"`Cl�•�,���f>~T,CU�
,K) BOX, 1116
9495 RMC 11.10 OF C, i"t.Y.[fil1MDR.
LA QIJ TJFi CA 92258
LA..QT=TA CA 92253
060)771-1941 L S<t "259
USE.OF PERMIT
SWI) a LOT ..1 b'%.!' H .1Q. PtYJ41T 1102S k40T 11 (2,1j0p, aL- OCK WALL.%
A
CUSTOM COMITRUCT1014 2,Q0D 3F
PORCH/t; ATIO
WILAWM CR.Ik47 OF CO3PT91XVI,.R:iC01 :..
MAIM()
P I:.AX GHFW N' FZE 101-000-439 3 i Ott .
MEC1ffAVICAi:Y1i',+� 101-000-421.000 MOM
-s��p•� ?-�k�[
}F. j�yyl't1�j"��']]Xyy�r�C[r�"A1.:�j177PErp q1 /fy111�)Li��t?� ggk�sp�.�g4
d� ld4.dl. 0114 i' 4,&'r '. .. A Vf'b � vJ V'�✓'"'�. S a�a `1'tFV �! S'�a?4 d
SVI:•„ 1'N0 M01110H VE E ;E M10 101-0191-241-£1W , ��C.01
101»�� 00—X 23-0 �A ��' ((M
�Cg4��lyi�'�1N^.Cp1�j�1y?(dy+E yy p g��p
t Ey/•1 xy"�.p 4Bri
dAiy
�:i��'pf:�rTw USE �1 6 k Ppp� ^S ,/,9 g^ ,r�gt
y4�'At:/b�,✓tJ�'gYY' 7i:1,;
�Y.`�,'1 W PUB,11AC C".I.�ix�.rJ:a! � 7i.GSE .270-00.0'F"Y"'Ye -000
. f �
6
r;
SUB-°3.`O:t:AL g'i `>,1,Rli'RUCTIC)N.PMD PLAN CTYCX
$1,583,76
IM,
$0100
NOW
t
RECEIPT DATE
BY { ID
E FI )ALED//{
INSPECTOR
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE '--
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _ _ _
f Z %
Underground Ducts
Ducts.
Slab Grade
2. ]
'Return Air
_
����
Z� �+
/
_
Steel
Combustion Air
Roof Deck
Exhaust Fans
'
O.K. to Wrap
Z��j = (_
F.A.U.
Framing 2Z , `�`
Compressor
Insulation
_
Vents
_—
Fireplace P.L.
_ _
_
Grills
_
Fireplace T.O.
_
Fans & Controls
_
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Irit. Lath
01.
Final
��� ��
Final
���
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
—/j— DZ
Approval to Cover
%
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping.
PLUMBING APPR VALS
Gas Test
Waste Lines
Electric Final
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)
— --Z
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
w
,
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)
_