SFD (0301-032)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
74€f?4 :s3 k ti3 ;a 7/31fM
elb'aa `� Signature of Contractor„ J
OWNER -BUILDER DECLARATION x;
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, amexclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). „
O I am exempt under Section B&P.C. for this reasori
Date Signature of Owner
It 1,
t WORKER'S COMPENSATION DECLARATION
I h_ ereby"'affirm under penalty of perjury one of the following declarations:
(,) .I have will maintain a certificate of consen
et 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 7P.Tr;:I'1r1?: Polic1. y No. • . G�#dr.'-x().43
,.BUILDING PERMIT
DATE VALUATION LOT
JOB SITE
ADDRESS %+yCIQ��LlDe4'3'
OWNER tij v.
TUDEM0 T S.TF_M'',1:2�'J 01Q`.e .
!. QUTAi7:A CA 92253
PERMIT#
TRACT
S
2943-7-3
APN
94q7-
APN cs rrnn qq ;
CONTRACTOR/DESIGNER/EN (NEER '
LA QUW. A ' , C AV2.2.3 k
i t .2990
Sx'O1ZCI�4L�.Ai`i'LfJ ,. �fi'l.fip air'
QARAt LJOAR�'Jit9 61.4,00
(, ,R 'fig
X4 rZD COST M? CONVmDano'N
'rES
YERK SU#VdfkiKt4RY
IMPORTANT. Application is hereby made to the Director of Building and Safety
USE OF PERMITa
(This section need not be completed if the permit valuation is for $100.00 or less).
r
10) *400418-000
X,06%�[t.
(• ) 1 certify that in the performance of the work for which this permit is issued,
P'U%N C;HFCK ME
101-004.'39-.31S
sni im
S1OD=WT 521PL.A14 Eli PL?.!,JA1T D9v➢PSNOT'i7'aO,'�Ux)E
gLt)C'!C"Wo1E.3.:,,
,
ilT, ISPA OR Oi'.i'4�E'�dah,$' t,POR613. 'W'Ya P1.ilA CUEM PL?3
PEDUC:T10N MR MULTIPLE 1SSIi /+MC E OF SAME N - 4M TYPB
workers' compensation laws of California, and agree -that if I should become•TsG�IAl!1�
subject to the Workers' compensation provisions "of Section 3700 of the Labor
Rl.ls'CUIC',AL PEE
101 -0 10-42-8 OO
Sx'O1ZCI�4L�.Ai`i'LfJ ,. �fi'l.fip air'
QARAt LJOAR�'Jit9 61.4,00
(, ,R 'fig
X4 rZD COST M? CONVmDano'N
'rES
YERK SU#VdfkiKt4RY
IMPORTANT. Application is hereby made to the Director of Building and Safety
(This section need not be completed if the permit valuation is for $100.00 or less).
CONISTRUCT19N ''
10) *400418-000
X,06%�[t.
(• ) 1 certify that in the performance of the work for which this permit is issued,
P'U%N C;HFCK ME
101-004.'39-.31S
sni im
I shall not employ, any person in any manner so as to become subject to the
, ,
iX,�.
10%�(�GrU�4 1 „(pf?
I
workers' compensation laws of California, and agree -that if I should become•TsG�IAl!1�
subject to the Workers' compensation provisions "of Section 3700 of the Labor
Rl.ls'CUIC',AL PEE
101 -0 10-42-8 OO
2. Any permit issued as a result of this application becomes n I a
Code, I shall forthwith comply with those, provisions. /f -
'"" - �1
i'7 tildltllINO FFLI,
101-000.4.19.000
IS11A. -5
Date-Applicant—..'d
ST"? NO MOTION ''YEZ, M11;
101-,600.241.-000
r:
Warning:Failure to secure Workers' Compensation coverage is unlawful and
r3RADR3•C4 ",T+
101400-423-000
51$100
shall'subject an employer to criminal penalties and civil fines up to $100,000, in
'DFVY3JOPJTA1 Wi~ACT FEE
the above-mentioned property G'inspectiod purposes`
4405.00
addition to the cost of compensation; damages as provided for in Section 3706
ART IBX IJUMAC PIA0.1, - MOM 9,70.1000.445-00 i
351,13
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 &e son at��
whose request and for whose benefit work•is performed under`o
-a &'.sh I
suantto
denacifjth
a r
any permit'issued as result of this,applicaton agrees to,
I
& hold harmless the City of La Quinta, its officers, agents an
loyees.
2. Any permit issued as a result of this application becomes n I a
d voip�{f�11
YY
a I
2 2 03
work is not commenced within 180 days from date of issu e
of sl7Eh
permit, or cessation of work for 180 days will subject permit to can
ellation.
I certify that I have read this application and state that the above formatig moils OF
LA QUINT' : 7 `
correct. I agree -to comply with all City, and,State laws relating4't AIN
DEPd ,
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property G'inspectiod purposes`
RECEIPT
DATE
ate
,,Signature (Owner/Agent)" ` Date'-
41..
1, COnt DRUC 0,14 .ATM. PT, MTRZK.
i ,1ST` Pls Z'b�`1Z.Sr 1'l..aTOTAL PYRMWIFEKES IRTE NOW
DATE FINALED
IN
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—__v
Return Air
Steel
2 — —
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
—� — 3
F.A.U.
Framing
Compressor
Insulation
3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines a))o
2— 3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring r.
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: