SFD (0111-177)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 -y# yLlc.. rClass .,,A -°ti Exp. Date
rq p
Date ?•A � Signature of Contractor
r
OWNER -BUILDER DECLARATION
I hereby. affirm under penalty of perjury that I am exempt from the'Contractor's
License Law for the following reason:
( ) I, 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). r
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ' .
() lam exempt under Section B&P.C. for this reason
Date. o Signature of Owner
a
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.
( ) d 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 STATE FUND . Policy No. D4�„X38
(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;14rid agree that if I shou, lgl�ecome
subject to the!worArs- compensationiprovislons of Section 3700!o1 t e tabor
Code, I shall/forth th comply with,;those provisions, �^ "
Date:/1_/(1Applicant
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.
A. 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, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information, is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby autherjeZe representat,i�ves of this City to enter upon
the above mentioned property for'inspecYion purposes.
Signature (Owner/Agent).--f Date
BUILDING PERMIT PERMIT# e '
DATE VALUATION LOTt TRACT
ft . , M6,lialtA l0 ' 29457.2
JOB SITE„.
ADDRESS 79-528 MISSION 1J YR XMYf
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
�E I`t .fi3 i:u
i�i.7M a �i,�C”' ION
TLO lio? C 1716,
'19-295 MR -940 i. �hQUMADR,.
i.k,Quwrt� CA 92253.
U.Qt:7IWA CA. 92253
USE OF PERMIT
1511140 FA7.YS.f..L DW174U.rititl o
11F 10 k'.E OA7d. t�FoBtMxY' WE;; rate Ii�t�ik.Llt:�lt P.LOCi� Ot,''�A4I,S,,
P00114 911A OR DRIVEWAY APPPOA,CM
CUSTOM (.1ONSTRUCITION Z1,914.0 lif
)h'Olr2w:.HlP.b TIO L M.00 3F
0.4,11AOFICARPOR.' , 470,00 '21)7
'Rs - mum, 9 con ok Commuc1:'.EoN
2-110,13.7,10
ky'SaW f�91. •
4StR�zE/f+��TYA"aa
(p! A Nt'
COMITl.t8t!!:'k'AON FF—E, 101-00014118-.000 �Adg7.� oo
Cr?.: -`Aid CHECK 1 FE 101-000-43P-318 $233.34
MECRAMICAL, M 101-000=421-000 $130,54
I' T '>; C RIC` L EKY; 1011-000-420-000 $16944 .
TOLUMP'TltO FEY: 101-000.4119.0(19) $9:15M .
S ROP0 UbTIt; N FEE . -{MID 101-000.241-0ee' $24.01
CU7IM FEE,101-000-423-000 $51010
fit
nE PADPER )IMPACTiLC1dy.Y�%G'id
ART ,"P AIRL ICL -LACI 5-RES11 VCI-OM445.,000 $100.29
MAL PER M l KEN DIM NOW
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RECEIPT
DATE
BY
t��;
DA Efl E
d
INSPECTOR
,�I..t •�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
�
Underground Ducts
Forms & Footings
Slab Grade
Ducts
_
S
.�
Return Air
Steel
ombustion Air
Roof Deck
O.K. to Wrap
�-- _ '
Exhaust Fans
y
F.A.U.
Framing
�_� g _ S
Compressor
Insulation
—��—
Vents
Fireplace P.L._
_
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
(a?$
Finala
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
Waste Lines
J_
4
��
Electric Final
Heater Final
Water Piping
// o
Plumbing Final
Plumbing Top OLd
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
���/�
Pool Cover
Sewer Connection
o/�
Encapsulation
Gas Piping
l
Gas Test
_
S ��
Appliances
Final
COMMENTS:
Final
Utility Notice
'
�Z,3
(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)
-,