0111-207 (SFD)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
04974
Y�'. .,*
Date � * a. � Signature of Contractor
OWNER -BUILDER DECLARATION r
I hereby affirm under penalty of perjury that.l am exempt from the Contractor's
License Law for the following reason:.•
( ) ' I, as owner of the property, or my employees with wages as teir 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 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. ys:¢issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No. c►4ii-Sr5f173:!`�
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that -in the performance of•fhe 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 the�workeGs' compensation provisions of Sectiori'37,00^oft a Labor
Code, I shall forthwith comply with those provisions.
Date: ''?f`Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
.for a permit subject to the .conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each personat
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employebst
2. Any permit issued as a result of this application becomes null and void�fut
work is not commenced within 180 days from date of issuance of suC" !I
permit, or -cessation of work for 180 days will subject permit to cancellatiop1911
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prope for inspection purposes. '
Signature (Owner/Agent):'•-'= r Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT .�r f TRACT
020052.00 40
JOB SITS y
APN
ADDRESS ,,.
,9- r0 MM1101q OR 'R.Wo`
fA9-$(X)-•002
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TD 0' 'r 'R.:1;3Ia'E+°F""i OPMi NT
VARX3 C0901RUC;:100
PO D03K 1716
79.295 RANCHO LA Q11:3.K.cAPR,
3':.AQUMA CA 922:x:3
LAQ3.1INTA CA 92253
(76 0)7714941 0810 2996
USE OFPERMIT ?-9.
��g��
AMLY q py.p WO
310 ,14')T 40 Pa.,i(W KPIR, P R+:NIT DOIES NOT i'Ntv:t.,UDE BLOCK VV.A'1,L,%
P00iI, SP -k OR ztMMAV APPROAali
CUDTOM C018;I1`RUC 1'IU13 2i635:00 :3F
FORC'HIP. x,110 26700 V
0.'f<RAOFI A£tf'ORT 614.06 STS
r
CONSTRUCTION 101.000.418.000 %1,03,00.
PLAN C.HECK PEE 90
PLtJj!WtB,POO 17KE 101_000-41';9-000
Pa irr.c31t10 MOTION M • 'R.mw 101 -boo-241-0010 $32.09
GRADINO FEE 101.000-423.000 120,00
S3}:9?ELOPR~:'a: 1Yi11f.F.F',.0 i ME
APT W PLI'SUC! SLAMS • RUM 270 -000 -445 -OW
ESS .-PPM 1 _W
-_'` �
JS?.00
in 'IXYfA..T, :Pf Lf 11105D Me, NOW
RECEIPT
DATE
BY /
DA FINALED„✓//
INS E-21
.,a
L.�
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
— - Z
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
3� Z
Return Air
Steel——Z
_
Combustion Air
Roof Deck
0. K. to Wrap
e., — Z
Exhaust Fans
F.A.U.
Framing
Insulation
�_ _ Z
J- _
Compressor
Vents
Grills
Fireplace P.L.
Fireplace T.O.
_ _
Fans & Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
L/
Final��=
BLOCKWALL�APPROVALS
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
Gas Test
Electric Final
Waste Lines
— _- Z _
Heater Final
Water Piping
Plumbing Top Out
,[' _
U3��
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
o -
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 `7 /
Utility Notice (Perm)`'