SFD (0111-178)LN,CENSED CONTRACTOR DECLARATION
I hereby a I'rm urAer penalty of perjury that I am licensed under provisions of
Chapter.§ (cor nencing 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
0574 ('574 D 0 �w oil;
Dates z _, 4 ! Signature of Contractor
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
Thereby 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.
(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 thelworkel's' compensation provisions of Section 3700 of#the Labor
Code, I shall forthwith comply with those provisions. f
Date: /r �'.. _/ f 'Applicent P .� ' i o
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and. Safety
for a permit subject to the conditions. and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant.to
.any permit issued as a result of this applicaton agrees to, & shall, :indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null' and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, .and hereby authorize representatives of this City to enter. upon
the above-mentioned property, for insp ctiorvpurpos.
Signature (Owner/Ager ` Date'?
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0!$'�''� �3 TRACT
JOB SITE
APN
ADDRESS !S d,+'% tw�!a�!��ti��a•11.
�A}^Qi
OWNER .
CONTRACTOR/ DESIGNER/ EN INEER
iir�•��r�
pp77ryry yy.��yy,�� ++
tD d.CFIllY.�rS'; I Ad�.4-.7.W.f)1?.1YA.:%cGY:T
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POBOX 2°916
19-295 RAiNCf10 LACrt3itTTtADR,
L.A. QUDUA, CA 92253 -
LA QUWA, CJS 92M
1,-70r1171-1'•341 CE:6:R 2996
USE OF PERMIT
sy'#:3 ix'. F,AMIN DWEL ING
NALI
P001, uPA c� ��a�r�ar.� WAY APPROACH
COCTOAM C01a`3T1dJC:T10N 4675.0 Do
a'��gORC�t-f>yrRAryryS.ZR'I�O
T d {f(i'�. �try3 QSF
` S.�A'M.Rd•Ldr�l'�lS:•2:1.Ei�L•6Fb b+ d1�6�.VYJ W➢•'
(:cfATRtiirTWOFEE 10)-000-41A 6.,000
VLXN CHMCK.f3`It rl 101-0(10-439-'318
M"RCA II J,?,1i:9 101.000.421-000 $M.6W
1GUZECTRICA L ",F, 101-000-420-000 *16zol
t'1V.eJ.r ftP9(YFYZ lot -000-419-000 $170.2S
S z mamrniovjm � - .VI) 101-000-w -000 $TZ 0y
ORIAY NO FGA' 101.000.423-000
fv►Xti"9UIPER.IMFA !' 17X? f �t';9f1fi7.04
ART TM PUBLIC PLACF.8 -.11M11 70-00044,54,100 13
M. -TOTAL (:t.11=R�lJY"fff• N A ND, PLAC� ;�,
i TaESS PRE -PAD "T " :R
$0.00
'7
RECEIPT
DATEBY
'.11$
D LED
INSPECTOR
1.7- /--; i
t/11
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
a
APPROVALS
MECHANICAL APPROVALS
Set Backs
Pons 8 Footings
_ _
/
Underground Ducts
Ducts
Slab Grad -e
Steel
Roof Deck /J.9 ,
�_ �� _ _
�,—
=fir —[�
Return Air
Combustion Air
Exhaust Fans
O.K. to Wrap
Framing
_
2� _ Z
F.A.U.
Compressor
o
Insulation
-Z g y
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Condensate Lines
Party Wall Insulation
Party Wall Firewall
Exterior Lath
41 -
Drywall - Int. Lath
`-�
_ L _ ffl�'5
Final
Final
7_T
POOLS -'SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
-
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines )
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
i.q
Pool Cover
Encapsulation
Gas Piping
Gas Test
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)