SFD (0111-173)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 i' �\ Exp Date
0,1�74/ B HTCY 4311tic
Datef T` / ? Signature of Contract�r�
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).
( ) 1, 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. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
( 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:
CarrierPolicy No.
S1'ATT' MT1dD
(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 Section 3700 0 the Labor
Code, I shall forthwith comply with those provisions.
t r .
Date `+° Applicant
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 adthi)rize representatives of this City to entQr upon,
the above-mentioned property for inspection purpose . f/ f
t �.��
Signature (Owner/Agent) Date "
BUILDING PERMIT' PERMT#
DATE VALUATION LOT "� TRACT
JOB SITE
APN
ADDRESS 19,,:al2,ust`r�n,D[u6F.FJ -T
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M.13:0X Irt1 G'
79-295 RANO O.U.,qpva!',�.M
LA (ViDITA CA 92253
1AQUIN t"l: CA 92253
(760)771-1941 2996
USE O�F�PERMIT
7 y Y \(jj pG
SFD .• LOTO PLM4 1U. PERMIT i)DM 140T INCf,i O -F, OL£JC . WALL%
POOL, SPA. OR WUV rfV#ia'A,`s `T AP13R0ACH
CUSTOM, CONSTRUCTION t924,00,k)?
d-ARAGEICA18.?'G?RT 41t0.100 SF
YSMUTED C09f OF CORS7"Ri7'M-17 H
24011.1, 7:.1.43 '
M7Fd MARY
CONSTRUCTION PM 101.004-4I S -M.) $1,133.00
PLAN CHEC19 "Il 01.000-439-316 $z'3"d. "m4
NIFC-1I, NICA.1., PER,'; 101.000-421=000 $130.30
WCTRIC,A I, FEE ' 101-000-420-000 0-42v-000 $169.24
PLUMBIN0 T'PMy, 101-000.414-0(3x) 075171
STte013L3115107101kiFRwm1':1LSID 101-00f34AI-000 $24.01.
GRADINO FUM 101 -000-4U-000 S20.00
x" �EIVE'u"11PESt IMPACT PEE sl,g07,00
,ART )N ;PUrs1JC PL4MSi - RESIC 2,70 -OW -4145 -ON S1001; 0
r f:
SCI's-T(YEP L 60XI'TTRUMON PND PI.A9 t'H!?.CK
$3.,8,92.03
NOW
RECEIPT
DATE
BY.
D T IjVQLE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs/
_
/-�- �� 6�
Underground Ducts
Forms & Footings
Ducts
3---� z
Slab Grade
�/
Return Air
Steel
/�- -
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
— -45—
Compressor
Insulation
3-12
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath—//
Final
Final
b---z� '
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
Waste Lines
�Z� /�
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
3 - Z
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_ �% _
_/lam/
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
-
Utility Notice (Gas)
j- Z
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
6 2
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
2
Utility Notice (Perm)
— -