0111-245 (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
Dat el ;n. �� iSignature of Contractor��� `� r
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).
O 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:
( ). A 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:
CarrierPolic 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,
.l'shall notemploy any person in any manner so as to become.•subject to the
workers' compensation laws of California;.d) agree that if I s ould become
Subject to the worlcers' compensation provisions of Section of the Labor
Code; j, haft fort w thcomply with those provisions. .,.
°'.Date % Gi: 'Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
r 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 persori bpon 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 1.80 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 ent r upo s'
the above-mentioned property for inspection p rposes. i
Signature (Owner/Agent)
BUILDING -PERMIT = .PERMIT#
DATE VALUATION LOT 0111-'145 TRACT
7 99C b
4
JOB SITE
i ADDRESS . 79- 701 MU91011=VR' X .rS"ii
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
PGBOX 17.1.
�i.�A0MITA CA* 922SS
TJX: >�1T1��Sd�e Ck .9=53'
>470g)7-7 1-1941 C'aLfl 2996
USE OF PERMIT
21MOryU. F"p fY D 213I dO
3r>D- LOP&aPAN V, PutiN4T.As=NOT 114C3,tVF81A1VL.1,;
110011! IVA 011 RNEWnYACPROACH
CUSTOM CONSTRUCTION ?,924.00 SF
PCrRCI-WA'I10 243.W. SY
(3ARAOSiC°.A1tiPOBt!. 4700 8?
0N?I+6 TRUC TIC"ba ME 101.000-418..000 �1➢131.>Di3
PLAN CHR.CK FEF W7,24
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yG+gp. p'tip('pI'y� 111�j3$4�6C'3e=€30-�Qa}2, y0-(t'3C\ECly
A'Y•SL•�•F�JC9�5 Y�L� TdYV: i eV S °i+�"�FY°uo P'C«Uyl'Y!9 �i� 74"h Nil
S'3xi~imO:a4arlo''N 1�wz a .RESxta 101 -00 -ml -.0rdo $24.01
CIRANNOPRE 1(i'I��vt1E±' a:>dCti1C► S:'0.ti4
04MMVER IMPACT YVF 00
ART IN PUBLIC KAaCES - X.R811: 270 ,000-445-000 5100.29
jii.,0.P
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l(q�7yyyy T �y 4 >C/� r ply y�T pb,7 erytT�
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PRE-PAMPUM
$0.00
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RECEIPT
DATE
BY
DATE FINALED
INSPECT
M
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
/ _ —
L
Underground Ducts
Ducts
Return Air
Slab Grade )—� Z e — —
Steel
--3=�
Combustion Air
Roof Deck
$ —
Exhaust Fans
O.K. to Wrap
d Z
F.A.U.
Framing
Insulation
Fireplace P.L.
— —Q
_
Compressor
Vents
Grills
Fireplace T.O.
_ _
_
Fans & Controls
_
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS ccc---t���---
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
Electric Final
Waste Lines
Heater Final
Water PipingPlumbing
Plumbing Top Out
__ _Z
Final
Equipment Enclosure
Shower Pans
Sewer Lateral
Sewer Connection
4Y — Z
O.K for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
_
Appliances
f
Final
COMMENTS:
r
4
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) J