SFD (0301-023)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
i�i'z1CZ,4 u�it'y a' 'S /6;31110..
Date *f- ^' Signature of Contractor! l
OWNER -BUILDER DECLARATION t
ft'Th6reby affirm under penalty of perjury that I am exempt from the Contractor's
Gcense'Law for the following reason,
1 .as owner.of the property, or my employees withi wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
asowner 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. L Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm' under penalty of perjury one of the following declarations:.
(.) .1 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. e
{) 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 .3T&fh�I?UND 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 permiel,i 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, I shall forthwith comply with'those provisions.
D ted ��- 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 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, in
& hold harmless the City of La Quinta, its officers, agents and emes.
2. Any permit issued as a result of this application becomes null an d -if
work is not commenced within 180 days from date of issuance�s�ch
permit, or cessation of work for 180 days will subject permit to can on. J
I certify that I have read this application and state that the above infor ati is
correct. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this City to en r uponClF
the above-mentioned property for, inspection purposes
Signature (Owner/Agent) N 1 1 Date
BUILDING PERMIT PERMIT#
DATE VALUATIONpp��f.qq���TT, t q .yy Cis LOT N TRACT
ADDRESS �: MINISKI.OXIT _ JOB
APN
OWNER
CONTRACTOR DESIIGNER/EN61NEER
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USE OF PERMIT
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CUSTOM CrJ7;1STAO h'MZ,924.008
F°t RC" fa'a�A x bre 2311.00 SP
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Art- 'nom
COMO°rRUCTION ply 10)400-418.000 jj"i tw
PLAN CHECK F&C 1.01-.000-4394,19
ME0IAN ICAL FRU 101000-421-000
E1.ECTR.1CA1, POE 101-•000-'l?0-wo $169.m
STRr.FAt.Cf.Mr~Yr1C. H FLER> R:ES)Q 101-000-241-000
(}131 ID0i0 FE3 101-t 00.4,23 -OW it' WWI
1�L'"b'tEl,.OPER,1ltJ1PACT FLIP17. $2,405.0
WOB-TUTAL Ct; NOTCRU'CTIONANY) PLAN +moi'
1���k4Y1�.. FRE.- AiD PTIEV
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NANCE DEPT.
,�
RECEIPTDATE
BY
DATE FINALED
INSPECTOR
_-.- . 7
tE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ / — 3
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
_ 2 3 _ 3
F.A.U.
Framing
Insulation
—
— 3 --
Compressor
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
cj —
Final 3 .7_�S
BLOCKWALL APPROVALS
Final
steel
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 ,:
7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
ZPool
Cover
Sewer Connection
- 3
Encapsulation
Gas Piping
Gas Test
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:
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