SFD (0111-205)�• -� LICENSED CONTRACTOR DECLARATION t
Ir hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing withaSection 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # . Lic. Class �* - Ex .Date
`' � lir �•� � ft � 1 ����� � j� •.�' 0°aJ'�.1
Date %tet""=t' `^" ' Signature of Contractor. t�
• OWNER -BUILDER DECLARATION
I hereby affiredrider 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).
O I am exempt under Section B&P.C. for this reason
o
Date Signature of Owner
,? WORKER'S COMPENSATION. DECLARATION
I hereby affirm under penalty of perjury one of the' following declarations:
(-) ,,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:
Carrier Policy No.
ST.NiY;FUND 9s"
(This section need not be completed if the permit valuation is for $100.00 or less),
( ); Lcertify that in the performance of the work for which this permit is issued,
shall hot employ any person in any manner so.as.to become subject to the
workers' compensat+on laws of California, and agree that if11 fi°Id become
subject to the�wor'%rg': compensati6n p �risions of Sec jon'3700 of the Labor
• Code, I. shallfforthw th°com I with those � 'f �%''"``
} p y � provlslons.,•;i'' � . {. - z
Date i':C-5f C� P•'P �' Applicant r r t ..• ''
Warning: Failure to secure Workers' Compensation coverage is urilawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
•any_perm'it,issued as a result of this applicaton agrees to, & shall, indemnify
& hold. harmless 'the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void, if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit V.4 cancellation.
I certify that I'have •read this application and state that the above information is
Correct. l agree.to comply with all City, and State laws relating to.the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property-for•inspecti�o°p pu'rpse`§
Dat
Signature (Owner/Agent)_ F t.r e
PERMIT#r.:
• `BUILDING PERMIT
DATE
•1 LOT "°v,"[� ' 0111°�� TRACT
-°•
/VALUATION y �P,�ryf �qry S
.4R? ' 294
JOB SITE
ADDRESS t9-592 .Y•/ DR,10JR ,O. MA rE ZA.S°
APIN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
`'i`i;4 5. `1° , .C➢ �t' Aa t:
�1�. � t:4:9'AlST'F"l'T`Ma014
PO !:kC DXr.1716
9.295 RANCHO XAA QVIN111i �R, •
T:..AOiJ'I:P4TA CA V2253
U,QUWA CAL 92253
(7 6(1)771 1941VI. a996
USE OF PERMIT
G'
r
3.10 • €. T 39 F14NI fl:IX PE AMIT ED09S',*•qOf .JNCj:U6X Bf:,f:'CI:;?B A1,14
POOL, SPA ORI. DWE TVAY A.1"PROACH ! .
CUSTOM, COMITR,U TION Z0351 DO 3F.
Sp
zWtAGF..fCARPORT s S .U0 p3T .
"�JTflt# i°3 Eg COQ? ' CONOM
r
220 00.
�O��.s�':�,tacT;s���� a�� a e�� ���v�f T �-��c, �;'.p>��,t►�
r. ,
FLAN CH'WK P$,'Ir 8 %217.90
M :C'H.ANWt.~e1..1+'R Y 3 t3Utl•,42 R�0°li) Safi °{3L1
1�t G` z339✓,1) I, Imo: 101 -000-4 a.0-600 $162.01
P111)VIDINOPr's 1X31tiC�i�-�I�a-tt;10 $179.35
S T i2ONO t1rlOTIt7" d FE' - :I�:1r I D 10) -000-241- s000 $29.09
i'1'RA:C}:l 40 FEZ 101 -OW -423.000 $20.00
r.?WPAr PER, IMPACT 1q8
AR't W PUB1,10 ,P -LACES - REX% .270=000-445-000 -
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tJC',"�'C`i�'A4'�.f9I3T...t,�I3 C`!c£�O.E"=.1•�,
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'BY
DATE ,NAL
INSPE
7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z, ZQ, z
Underground Ducts
Forms &Footings
2 2, Z
Ducts
_
Slab Grade
�_� .
Retum Air
_
Steel
2 , 22, a
Combustion Air
Roof Deck
O.K. to Wrap
3 Z
S /j -Z S
Exhaust Fans
F.A.U.
Framing
/ —
Compressor
Insulation
_ S
Vents
Vents
_
Fireplace.P.L.
Grills
Fireplace T.O.
Fans & Controls
_
Party Wall Insulation
Condensate Lines
Z-4
Party Wall Firewall
Exterior Lath
-5 - Z� -
Drywall - Int. Lath
_ y
Final ��p�%a
BLOCKWALL APPROVALS
Final
-
steel
G)_�/- 5
POOLS -SPAS.
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
Electric Final
Waste Lines (=�-��
Heater Final
Water Piping✓_
_
Plumbing Final
Plumbing Top Out
c�
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2=aS
Encapsulation
Gas Piping
Gas Test -
Y-
Appliances
Final
Final a
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 v
Utility Notice (Perm)
COMMENTS: