SFD (0111-170)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... ' f"
License # Lic. Classy,.., Exp. Date
674P 4/f
bate/ ' ,' "'.�'f Signature of Contractor W a,
OWNER -BUILDER DECLARATIQN
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 10 construct the `project (Sec. 7044, Business & Professionals
Code). -
(). I am exempt under Section B&P.C. for this reason,
v �.
Date " Signature of Owner ti
WORKER'S COMPENSATION DECLARATION
I her 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 providedifor by Section 3700 of the Labor Code, for the
performance of the work for which.this'permit is issued.
( s) 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:
Cartier STS". 1t�.iit2 Policy No. 04(.00G"33
(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 pfoVisi' ns of Section -3700 of the'Labor
Code, I shall forthwith comply with those provisions' 1
Date: ti' ' ', Applicant
Warning._ Failure to secure Workers'`Compensation coverage is unlawfuljand
shall subject an employer to criminal penalties and civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest.and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions -set forth on - ,his,
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose,benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to; & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. .
I certify that I have read this application and state that the above informatioh is
correct. I agree to comply -with all City, and State laws relating to the building .
construction, and hereby authorize representatives of this City to enter. upon
the above-mentioned proper"iy for n'spectiopo'u uses.
Date e �' aSat 4.
Signature (Owner/Agent)"",,"*
r
..--BUILDING , PERMIT PERMIPERMIT#
DATE VALUATION LOT"� TRACT
JOB SITE
ADDRESS 79-4:+'0A)Waz�9r'SIONv D3 MM, PAN-).- .,$
APN
�49210.062 `, v.
OWNER
CONTRACTOR/[ / EN INFER
` III D01W.1 17kVELI,,grMION f'
% lit' k ;C
iA C.AMAT.A. CA 92233
LAQt:MTrA CA 92,2S3
C3� tai 1. cyns x.906
-
USE OF PERMIT
Mf"u , l.,CS'1' y 1"^i,,A N ,Lu: i6 RA41 WES"NOlf V.JC;..ilD8L 8LOC K Wh3.L-1,`.
P001: SPA OR. Dkt,FVVWA1,Y PROACH
(14RA.G1?9t".AJRkk)RT 47D,00 SP
XSTMATM COST OF CORMAX170H
240,1.17.10
CONSTRUCTION YEP, 101 -000 -418 -NO $1,133.0Dr
4bGtSW C"3,;i1+�,:1L
14 C ISICiA L, ME 101-.WJ-42 9. 00 $130,150
1r.1�; 'CT.4RiEwA . FS& 101-000-420-000 $169.74
"r^1MAK140 ME yCA"1 •,i}l�f�� f9uC5�J0 Sl'?3 i3
STR0140 WIOTIOW iTM, a R2,41]D ' 0Y 0b0,441--004 4:ST1
ORAaiM0 FEE 10.4*0a423-(K)0 20,00
D.7Y&=pPPl1R IMPACTFZX $1,$07.00
AdItT rraPUBLYC PIAC&, RV,31L VID-00 -445-000 MUR
SOI',••i�t�'�;Ax,�:J� .�,?:�8�1(TC'i� ���iL���9�fC��l?�"`1ti'
$3,892.0
I"I P:€:i{dP/.31�:F.W_90
'Saw
NOS
RECEIPT
DATE
BY
D E F ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings ZI1 D��
Slab Grade l _ J�
Steel �_ , �wv
Roof Deck N ,.Y-5 2
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
O.K. to Wrap o
F.A.U.
_
Framing 2 _2 _
Compressor
/_,;�_
Insulation _
Vents
Fireplace P.L. _
Fireplace T.O.
Grills
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath _ZZ pZ
Final-��
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
c5,•�� �Q➢� X21 'Z
Final �d_
PLUMBING APPROVALS
_
Waste Lines f Z �� /'�!i
Water Piping
Plumbing Top Out —2, -92,
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final �a
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 /
Y::�of Power 5 6-W
Final �d>
Utility Notice (Perm)