SFD (0301-020)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 : ' . Professionals Code, and my License is in full force and effect.
License # Lic. ClassExp. Date
�.wr 74074
Z Date %' 'Signature of Contractor
O
J V,� as:,, OWNER -BUILDER DECLARATION
H' arm ,] hereby affirm .under penalty of perjury that I am exempt from the Contractor's
'Llcense,Law for the following reason:
Z ( ) I, as•owner;of`the property, or my employees with wages as their sole
compensation, will d6 the work, and the structure is not intended or offered for
Sale (Sec. 7044; Business & Professionals Code).
as owner. of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).: ;
LO " O I am exempt under•Section B&P.C. for this reason
n N 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.
(.,1) 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 OT,e'1:Tp. rAJ NT). Policy No. 046-17M-:200
(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` Wat if I should become
subject to,the,workers"compensation provisions of Section 3700 of the Labor
Code, I shall,forto"th comply with those,pr;visions. .,
Date: " Applicant t
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. r
1. Each person upon whose behalf this application -is made & ea p rsori at /A
whose request and for whose benefit work is performed under o u ; uantte =r
any permit issued as a result of this applicaton agrees to, & sh riemnify
& hold harmless the City of La Quinta, its officers, agents anPloyey;��%�
2. Any permit issued as a result of this application becomes n a d void i
work is not commenced within 180 days from date of issu ceh
permit, or cessation of work for 180 days will subject permit to cancella4liin( OF
I certify that I have read this application.and state that the above In o FINAL,
correct. I agree to comply with all City, and•State laws relating to the building
construction, and hereby authorize representatives of this City to.enter'upon
the above-mentioned property fog inspection purposes. f
Signature (Owner/Agent) Date AI "
,
BUILDING PERMIT PERMIT# '
0301-020
DATE VALUATION ' t LOT 40 TRACT 234541.4
"2JOB
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SITE:
ADDRESS 7�.L_Yia'
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CA 922152
LA Quwhk
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USE OF PERMIT
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ill e. i.IVi. ;b. �!',�.`c1. C�e '•,
?YfMUCTta11 FOR. MUII b'1PIZ ISSUANCE OF SAME fi+IAN 11q,)Y;'
CUSTOM C*01,140TRUC;TtC+N 2'w"09 7F
PORCiYP, P10 26+7.010 S.t? '.
(WWWCAUORT 614.00 V
I'MulT IWI. SUMMARY
C,QN;t'J'RUC'fION RE 101-000-4118-1000 $1,06r;Am
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PLUMB)NO 1+7
S R€i 40 MOTION FY -2 _.WD 101..-000-243-0100
OR.ADI N& F 01-i100� ;i W J�3f� l �v,41tt
D, ILOPX4 fMP.AVP FE121 $V0:5,00
ART IN PURWC PL,i C -01'I - R t ,Z.70 -(?00-445.000 952,13
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RECEIPT
DATE
By
DATT� FINALED
INSPECTO
?
N
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/
_ ���
F.A.U.
Framing
Compressor
Insulation
_54-2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
14
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
2../Q —e;
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
bj
Equipment Enclosure
Shower Pans
ZO.K.
for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�,� w . 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: