SFD (0111-176)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptor 9 ,(commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my'License is in full force and effect.
License # Liic..yClass Exp. Date
674 p14 B mix
Date y' ? ? 4 {� Signature of Contrre6o' r� " -
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).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm underspenalty of perjury one of the following declarations:
O 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 tlie:Labor Code, for the performance of the work for which this
permit is issued. My- workers' compensation insurance carrier & policy no. are:
Carver Policy No. 04
6-0
00V
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1 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 thejworkers' compensation,provislons of Section,3700 of the Labor
Code; I shall/forthwith comply witvlt cse provis ons.
Dater Applicant
s..,
Warning: Failure to secure Workers' Compensation coverage is unlawful arid
shall subject an employer to criminal penalties and civil fines up to $100,000,jin
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 subjectto 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 authorize representatives of.this City to enter upon.
the above-mentioned property for Inspection purposes.
N
Signature (Owner/Ageni),,,•. -=N� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �'TRACT
),.1, 7.11 29457.2
JOB'SITE
APN
ADDRESS -�i�rS, 3,00 DRI ,F. '
EGD• aR
OWNER
CONTRACTOR / DESIGNER / ENGINEER
°i'D;iM�'.iKKI'DEVY12kyl."Wwr
�3'!?AWCS COIT3s';t:ktUCOON
P0 BOX 1716
7 9-295 RANa-1.0 LA QUINTADR,
LA QT9•,CtN`xA CA 92253 -
I.AQIlD+iT.A 4..13. 92 253 _
{ 6 r, 14 2"6
USE OF PERMIT
af?1:7 . JXxT 91?I: A.14 tk PfCRM17' D0R3140T INC1,UDE OL'OC K WALI.,S,
TOM 2,924,OD Sly'
1}4 pCryOipzySTRUCTIC'N
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0ARA0 ,J0AP,PC)WT 3p
IAERATU.T7. ' JiNALARY
MtbONON FIRE' 101-0(XI-4l8-00
PLIAN CN-Ir"CIX VE
MER,HANICA111fWIVE 101 -00"7111 -ON) SIX"
r~:I.v.,'i:'I RII< AL FRE 101 -000 -420 -OW $169.24
MIUM51140 RIP, 101-000419-000 $17V75
STi10110IMMIGN FE2 - RMSID 101.000-2AI -C3®t3
0RADI 101FE 101-f? -M-423-000 $20.03
13V91,0PFIR ):MPACT $1.907.00,
ART 1y P iBTX PLAMS • 'f EME Z7.0-000-445-000 $100.29
LESP, PRT,?rAl[D FM
M00
MIA1.0 FERME a 'x,015 DUE NOW
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RECEIPT
DATE
BYDA
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INSPECTOR
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FI
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs/_
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Underground Ducts
Forms & Footings
%
Ducts
l _
Slab Grade
,1 �// ��
Return Air
Steel
Air
Roof Deck
/� _ �y z
_
Exhaust Fans
O.K. to Wrap
/3 L
F.A.U.
/C
Framing_/
Insulation
j
— - Z�
Compressor
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
_ _
Fans & Controls
Party Wall Insulation
_
/
Condensate Lines
Party Wall Firewall
Exterior Lath
Z -2—
ZDrywall
Drywall- Int. Lath
— 7,
Final
Final
'
POOLS-SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric'Bond
Footings_
Main Drain
Bond Beam
_
Approval to Cover
— +
Equipment Location
Underground Electric
Underground Plbg. Test
FinalZ
Gas Piping
PL °TUBING
APPROVALS
Gas Test
Electric Final
Waste Lines`Z/
Water Piping
��
(D /
Heater Final
Plumbing Final
"
Plumbing Top Out
? / z
✓
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/ Z
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
S i - (✓/
Appliances
Final
COMMENTS:
Final=
1
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
42-
_
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
—�
Utility Notice (Perm)
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