SFD (0301-021)J
W
I—
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
6-74.074 D Bic
',bate '�` {g Signature of Contractor ' -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat I am exempt from the Contractor's
License Law for the following reason:
( ) 1; :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).
( )'. 1, as,owner of the property, am exclusively contracting with licensed
contractors,'to construct the project (Sec. 7044, Business & Professionals
Code)."'.."
(") I arr 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) 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:.
CarrierT.AttLI xrVt4L' Policy No. 096- � 2ifG3
(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 §ecti n 3700 of the Labor
Code, I shall forthwith comply with-thhoose,provisions.
Date: 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 V06
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 pOrsua-1 Ip
any permit issued as a result of this applicaton agrees to, &shall; Inde y
& hold harmless the City of La Quinta, its officers, agents and emplo
2. Any permit issued as a result of this application becomes null•and v�7c
�f
work is not commenced within 180 days from date of issuance ofpermit, or cessation of work for 180 days will subject permit to cancel) .
I certify that I have read this application and state that the above informat on i
correct. I agree to comply with all City, and State laws relating to the bu Iding
construction, and hereby authorize representatives of this City to enter lipi
the above-mentioned property for inspection,purposes. `
Si nature 10wner1A ent)l- rt 1"` �J Date° * r
BUILDING PERMIT PERMIT# .�
DATE VALUATION tbA�9l�,.C.S �, LOT 41 TRACT 29.1517-3
JOB SITE ADDRESS 79-'62a A,i.9.�ii3�7.1.«ba "MAPN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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USE OF PERMIT•,
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pe fa.t.�,
P001 , h"'Y1PA OR DRIVEWAY 7PA $ J` S.�A��i.M�:�'2CH,� 505 F�9..t�'!�Y C RC!. 4. 1'r,''t;S'� .
RE V01t c1l TIVrl;PI•pk; ISSUEMCI.OFEL WE MAN 'i'YVF'
CUSTOM C QrJ'.1,IT.KUCT1ii�8 Z924190 Sig
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PERM,
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coms�muc 1oN m 103.000.418L-000 $1,1no .
PLAN CH1,M:a VEEP, lot -000-439-318 $a {x: V
MC+; RANIC,f L IVE I p1 -ti 0+ r t)i? $130.50
NL.£ C P)i:ICA1. Zs'1 W) Sf#?. rl C -djfdCl $160.24
Iii T!3ONO MOTIMI FEE - RU..i`O 101-000-2-41-000 0 V-441
OPIA]:1 N0 104.-.000-4-23-000
MY MOP�flt IMPACT PM
,AU N P1.I,t:33..IC PLACEUI • R.Ult .270.000 44,5- tGD l
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NOW
AN 2 2 t-903
ITY,OF LAQUIN' A
FINANCE DEPT
RECEIPT
DATEBY
DATE FIN LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
— S
Ducts
Slab Grade
_
Return Air
Steel
_ 2 ?—_5
Combustion Air
Roof Deck
— �! — ,�
Exhaust Fans
O.K. to Wrap
3
F.A.U.
Framing
_ —
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines 01
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
—//—
POOLS - SPAS
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 Lit
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
e
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
— 3
Pool Cover
Encapsulation
Gas Piping
Gas Test
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
Utility Notice (Perm) — A