SFD (0111-201)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. Date
Date �,• Signature of CO'�••�-•� �"
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 (Seca 7044, Business & Professionals
Code). I .
() I am exempt under Section B&P.C.. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I 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.
t ( ) 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:
Carrier,,,TAT9 FIRAGr Policy No. 040.00M39
(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 mariner so as to become subject to'the
workers' compensation laws. of California, and agree that o if I should become
subject to tfie/Workers' compen satioyerto�visions of Sectionf3700 of the Labor
"Code, I shalllorthwith comply with those provisions:'
Date: ? > Applicant
Warning: Failure to secure Workers' Compensation coverage i -s unlawful and
shall subject an employer to criminal penalties and civil fines up to $1000001 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 aQtrhorize representatives of this City to enter upon r,
the above-mentioned property for inspection purposes'-
Signature (Owner/Agent) +' t •,✓ Date V X,
v .
BUILDING PERMIT - PERM T#
DATE VALUATION LOT j,-�.S�i TRACT
/ %7 . e._ . (,1 x�n �'t�a � �.� 34 19457-2
JOB SITE
ADDRESS. .7 76 KISSION DYJVE R 37
APN
64%1W' ' .
OWNER
CONTRACTOR /DESIGNER /EN1NEER
.013yS6Fb.eJypap✓,h6dT
IGdWbLUyglrN
10 1 17.!1
rxt}a5yd��y
.[d
(760)7711"1941 t.fMA 29916
USE OF PERMIT
00 � )`;;''94� .PL 14 PA. Safi+:!?lirEIT WES 140`3' 111 -IC .XYDZ ffLAXX 'S AIJ-K
P'004 SPA Ofd. WWWAY APPT 0ACH
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1 ��'?l� WATED COST VP COMMW'fl
240-117.10
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.
PL*4 tw3 J 5::. 1da a�?A=Gt>�f�;'3•��'-:�tf! ��5.�:ad.
' TQC""4�rt3p,T��RIC•AT, FRE $00.60
8101*(0�J(��,0-AtZpl�,.,p��[3��¢.?
101 -W.0 -420 -WO
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ART IN PURIA0 PLAMW RUM 27"00-44-5-000 S100129
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KID -TOTAL C"CYz31 MUC QTON .iA.'�fD PLAN CTNO'K
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RECEIPT
DATE
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
:� . 27 Z -
a 712
2.. Z, 2
��7,2-
Underground Ducts
Ducts
Return Air
Combustion Air
'
_ _
Roof Deck
3 - ZS - Z
Exhaust Fans
O.K. to Wrap
- G _
F.A.U.
Framing
Insulation
y• �p -
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath'_
Final
BLOCKWALL APPROVALS
Final
-
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Waste Lines. _ �/�
Water Piping l/_!r "
p 9
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Plumbing Top Out
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
_
Pool Cover
Encapsulation
Final
COMMENTS:
,..
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring y -�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final �®
-Utility Not (Perm) - �.