SFD (0111-169)^' 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
bat -1 _ - , Y % ,Signature of Contractor � •
e
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 to construct the project (Sec. 7044, Business & Professionals
Code).. r
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�proViided 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 . rp p 1 Policy,No.
n)"�97.•i"�A"ii.i.�.i=f .b'�57•��i.�l i.,�Jl6'
(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 provisiorislof Section 3700 of.th�e;Labor
Code, I shalt forth - ith comply with those provisions. t
Date. Applicant—.,Z 1 H
Warning- Failure to secure Workers'"Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of'Building and Safety,
for a permit subject to the conditions and restrictions"set forth on.'his
application.
1'. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to,'&.shall, indemnify
-& hold harmless the City of La Quinta, its officers, age nts'and'employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date'of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that l have read this application and state that the above information. -is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize ' rep resentatives of this. City to enter upon
the above-mentioned property for inspection4purposes.. ow
t f,. '.
Signature (Owner/Agent)1w•• t Datel.-t•el
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
2 2907-21
JOB SITE
APN
ADDRESS 79w4,915INMUwXO. IDIUd E BS"
OWNER
CONTRACTOR/DESIGNER/:ENGINEER
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7.AQ$)?MA CLS, 92253
1..k01T"m CCA, 92253
(Un.)771a1941 t•'a31'_* 6996
USE OF PERMIT
If
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Pc.'ol, LPA #1R1�f1
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CONOTA:cX•s10141 ITIS '901-000-418-000
PLAN CHECK M1C.' 101 �00043931 8 tg?l :61
4 C'1 trliC° 3.FER 1X91-tOM, 21.00 $401.413
KLECTAICAL FEF 101-000-420-,000
VILUMBNO Me 131-000-41 5�-00.0
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V.LW'ELOPER, Yf A ACT 1�'N.:f? ~rN37:6ff1
,ART IN MEMO O iPLACU - USKE70.000.445.000 $3 , 43
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TMIJU, PYNbirr IMP. TE NOW
RECEIPT
DATE
BY
D E F L D /�
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
�Z ��
Underground Ducts
Ducts
.—�
Stab Grade _�
Steel
Return Air
Combustion Air
—
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
_
Framing
2_"S
Compressor
Insulation
?, _
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
_ _
Fans & Controls
_
Party Wall Insulation I
_
Condensate Lines
Party Wall Firewall
Exterior Lath
3 —
Drywall - Int. Lath'—
Final��-
Finald
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
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
% Z7��� ��
Heater Final
Water Piping
(
Plumbing Final
Plumbing Top Out
_ _
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
/�
Pool Cover
Sewer Connection
_
7/"` v /
Encapsulation
Gas Piping
Gas Test=fid
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)
-�