SFD (0111-179)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.,pate
Date'`��!� 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..
Ihereby 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
performa'nce.of thework for which this permit is issued.
( )
[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 Policy No.
�'T.�i'y F 1 i ND ��4f1-6r9A'733fl
(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' compensa on laws of Calif orn a;�and agree that if. I should become
subject to the•workbrs' compensation, provisions of Section^3700 pf the Labor
Code I shall'forthwith comply with.'those provisions.
Date '�,.� Applicant �w... _; a, t..�. • I. .
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 pFovided 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 _autfiozR representatives of this City to enter upo
the above mentioned property for inspection purposes. i'.y!11
Signature (Owner/Age t) --f Date "
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 01-11-179 TRACT
12 29457-2
JOB SITE
APN'
ADDRESS 794�i��r1�%��`��a,1�'����bvr
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO BOX 17.16
'79-29S.WiN>v';no?.4Q)'C7 41A]3X
I�&k Q tnn%, CA 922 3
.C,A. qoDru'. CA 92253
(760).m.194.1 ru T 2996
USE OF PERMIT
MOLE Dda'l t' DWE T. J�'.9'
SPI) - L01" 12`'Pl,.AN FI. P1,M7MIT DOES IN CLUE)l RLOCi."WAW;
p
CUSTOM CONSTRUCTION 4635,061F
POx00ATIO 267.0015F
0A1?AOMARIPORT 3F
EUMN17D COST OF MRSTRITMON
2201=.00
pwldn ;1'j'AR sb1h 'int W1
w��1"�'�x3��g�i�a i"+3.I: 1t3I��C�(l�"s�<•�itli3 �I,��3.4J
PIAN
NIECkW41ACAL FEE 10 1 -%*421 -000 $105.00
XL EC T I U C ,S,1r'FLPI? 1 {r;-t�ti1��2��317ia ATG a.o%
i�i.�d�k3��'J 111, I OI �CCtJm4I �••�Gt� � i c9, 2�
C O%YCI ?ad0'T,I B!6 "1 Ir�r W €f. L= 101.. -000--241-t 00)0
C,R-ADI14(W � 1.91.F 101-000-423-000 MAD
DLl?kOPR IMPfCIP FEE, $11,%'7.00
ARTIN PUBUC ii6CM- RRUR Gp-WO445-00
' .270 -WO -445-000 "
y .
UR t� wPfi.L 'SIM
$O, C'*
0MIAL PrO&WVIZE0 DIAD&I NOW
13,728,M
RECEIPT
DATE
By
D NA
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ -
��J
Underground Ducts
Ducts
Slab Grade
_
Return Air
- _
_ _
/
Steel
Combustion Air _
Roof Deck �/
_ 2 j_ pz S
Exhaust Fans
_
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
- Z _ -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
v
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Z,
Final
Final
;d
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
l �/per/��/�
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
®
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
,l
/Z
Pool Cover
Sewer Connection
_ -/'
��/U� "���
Encapsulation
Gas Piping
rrr
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
_
�� D
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole,
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
_/,$ —0, --
O, --Utility
Utility Notice (Perri)
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