SFD (0301-019)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. IC Class Exp. DatRe' /
�Date:'kZ'. , Signature of Contractor
OWNER -BUILDER DECLARATION %
c( hereby affirm under penalty -of perjury that I am exempt from the Contractor's .
,License Law for the•following reason:
owner'of.,the property, or my employees with wages as their sole
c'o'mpensation', will`do the work, and the structure is not intended or offered for
sale (Sec 2044, Business & Professionals Code).
( ),.I as' owner of the property, am exclusively contracting with licensed
contractorsto construct the project. 7044, Business & Professionals
Code) ` K . ,
O 1 am 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:
(4) 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 have and will maintain workers' compensation insurance, as required by
Seetion 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. STATE PJND Policy No. 04fi-s):rig-2{14:1 '
(This section need not be completed if the permit valuation is for $100.00 or less).
a) 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 37001of the Labor
Code, I shall forthwith comply with those provisions.
Date: Z, Applicant -•y/) 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.
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,, ina I
& hold harmless the City of La Quinta, its officers, agents and empl S.
2. Any permit issued as a result of this application becomes null and I if
work is not commenced within 180 days from date of issuance o such -
permit, or cessation of work for 180 days will subject per mit,to canc I ti n.
I certify that I have read this application and state that the above inform do is
Correct. I agree to comply with all City, and State laws relating to the k uilding Cl.
construction, and hereby authorize representatives of this City to entE r upon
the above-mentioned property for inspection purposes
'Signature (Owner/Agent)•' Date L= - "?
PERMIT#
BUILDING PERMIT
. 0301-019
• � �� a ,�
DATE VALUATION VA40,1 11 uj . LOT ,.9 TRACTJOB
SITE
ADDRESS I°hP.�/IYFsL)T+s�:s'.
APN t"�(3Il•�
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'r0 ,DrJ.0F2 DEY W..W-r
S`i)ARKS C`.E>.N' iRi'.'1'gCt11E:31r1
PO W ', a T) Cl
CA 92Z.13,
LA 00INTA C4 k2:53
(160)771-1941, I ( f �' 299.6
USE OF PERMIT
mom r jm;# WELT„ (I
SYD 6 IDT 39, PLXrT E2, PERMIT VC']RS N ML::WV1?.11t,OM WAI,L•%
PiD01„ 151PA OR 1 RArr- AY "PROACH. 70% PLAN CHECK alt' .
Ri>33UCTIM YOR ta±li,li-TIPLEISSUANCE OF SAUL? Pldk3 l L'YPXX
Cus,rCm CmISTRLICi':ION 1,924.00 1117
0.1' COVIRMIU10IN
�1.�y5t,513m9awC"oiriy'
.A'-X+��..1Y.48'k,' �i��t� e,�[•l �Y�I.IYJ13-'L.CC...Ii 1,r
CONSTRUCTION PEP, -Iof moc*4,18.000 sl,.133,an
FLAN CHECK mr 101-000-439-316-'
11A'4s`i-111MICA1., f7ri� 1 ClAr'�t3Ct� si � f30 Yf• 4f1.3a .
3?L_p,,C'C'k,uCAt, VVE, 349- t1 - 1 .f2-ti3B X1.69. d4'
.:
Muhlbblo KIM. 1010300419.000 t17a,?$
STROND PAt TIOt3 FEE'- RRI.SI€3 101-000-241 X000- $ T�l.ifli
OIRADINTVIRE
I3f:H'I:iOPRII iMP-AM Ft�•E? O'a0it
Akr `.9i PUBLIC PIACES - RE SIL � �0-00044 a-0%)
a.
w ,7.'QQAL• Cia,R{ML9MONTAND NANG�k)EM'
' `IAL .eE�,�.'�f:T aM95 WE 00W
� IY"!po�S,y4 7eum
2222203
1Y OF LA CUINTA
INANCE DEPT.
RECEIPT
DATE,
BY
DATE FINALED
INSPECT R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
_ 7 —
Ducts
Slab Grade
-
Return Air
Steel
-2
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap_
F.A.U.
Framing
. 3
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Final
BLOCKWALL APPROVALS
Final — _
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
a /!7^
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
Sewer Lateral
_
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Gas Piping
_
Encapsulation
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 12 -
Utility Notice (Perm) - _//
COMMENTS: