SFD (0301-031)LICENSED CONTRACTOR DECLARATION
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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
c,4 Uj Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
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Date L:L-- Signature of Contractor
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F-, (0 OWNER -BUILDER DECLARATION
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-�..';he"rebyaffi-rrn under penalty of perjury that 1, am exempt from LU LU m the Contractor's
F- a� 'T',L`Icense La ' for the following reason:
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Z 1, as owner of the property, or my employees with wages as their sole
'compensati6n, will do the Work, and the structure is not intended or offered for
sal6'(Sec. 7044, Business & Professionals Code).
1, as, owner of the! property, am exclusively, contracting with licensed
contractors to . construct the project (Sk.,7044, Busines . s & Professionals.
Code).
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( )', I am exempt under Section B&P.C. for this reason
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Daiei —Signature of'Owner
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CL WORKER'S COMPENSATION DECLARATION
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C) .:-- , cr I hereby. affirm unde; penalty of perjury one of the following 'declarations:
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— 0 1 have and will maintain a certificate of consent to self -insure for workers'
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LLI compensatio6, as provided for by Section 3700 of the Labor Code, for. the
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performance of th6 work for which this . permit is issued.
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L) I have and will maintain workers' compensation insurance, as required by
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'tion 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:.
c r'MT9 FUND
Policy 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,
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 workers' compensation provisions .of -Section 3700 of the Labor
Code, [Shall forthwith comply with those -provisions.
Date-. Y"i % z. Applicant'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,600, in
addition to.the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney'sfees.
IMP*hereby Application is made . to the Director of Building and Safety
for a permi ' t subject to *tli6 conditions and *restrictions,", set forth on his
application. ' t. I 1 1.
1. Each person upon whose behalf this application is mad4 W -each perso t
whose request and for whose benefit work i6 performed un( r pyrsual�
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any permit issued as a result of this applicaton agrees to, '�Ill, indemnify
& hold harmless the City of La Quinta, its officers, agent,, Fnd em S
2. Any permit issued as a result of this application becom( n4ll an10,19 4
work is not.commenced within 180 days from date of i suqnce of. such
permit, orcessation of work for 180 days will subject per t to'=%'KnTE_A
I certify that I have read this application and state that the abive inforiniffillbANCE
• correct. I agree to comply with all City, and State laws relating to the. building
construction, and hereby authorize representatives of this Cjty to enter upon-
the above-mentioned property forl"hpectio purposes.
,,_,,,Signature (Owner/Agent Date L
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE i " .
ADDRESS 79.742M1,SR0XD)RM_PFA9f
OWNER
1170 DMIAT 0MLOPM MIT
PO BOX, 1716
LA QUWTA CA 9-9253
USE OF PERMIT
&P-0 - WT 51- Pjrt.N' E2. PERMIT rjdiv.s NOT 11
PVA 6
.00, L, OR DP4VEWAY APPROACH,11,51%
RXIDUCT1014 10R. MULTHY.Ls ISSRUA-RCE OF "S
I
CUSTOM C6NSTRUC110N
PORCH/PAM
A- 4M. (MCARPORT
APN
/ DESIGNER /
SP
-ARK-8 COMARM—MONT
L& Q11M TA CA. 92253.
2996
JOR MeOCK WA1118y
xe,viecx FEE'!,
MAN TYPE,
MIN -AWN, COWS TRUCTION AND PLAM C]LUXX
Y=1
2003 "rowyrumff F's"a Inik Now
IPSUMATKID COIR' Or COMMUCTIOIN
MWIrr F=, 9M. WARV`
INA
00 1 V117 R U (11 T I 4YJq YU
101.0004MM
$1,133.00
MAN CHECK We,
101-000-4149-318
$232. ?A
MMANICA,L FEE
101-000-421-000
$130.50
MU=R=AL FEF
101-000-420-000
$109.24
PUMBYK0 'VEY,
S1,15"M
STXrJNQ MOTION FEE - RESID
101 000.2:11.000
$2A..01
GRADING PU
101 _000-4-2:5.000
1115A.)
W,VrRWP?,R IMPACT YP,.F.
$2�44 )$, 0D
ART W 1101,10 PLACES - ROME 270000-443�-000
$190.29
MIN -AWN, COWS TRUCTION AND PLAM C]LUXX
Y=1
2003 "rowyrumff F's"a Inik Now
M
INSPECTOR
f�y
DATE
INA
M
INSPECTOR
f�y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
—
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
_/ _
Exhaust Fans
O.K. to Wrap
1 _
F.A.U.
Framing
- S
Compressor
Insulation
_ / _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Party Wall Insulation
Fans 8 Controls
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 Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
-"
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2, 1 Q ,35
Encapsulation
Gas Piping
Gas Test
b�JT j
Appliances
Final
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)
COMMENTS: