SFD (9809-241)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C'4 W Professionals Code, and my License is in full force and effect.
O n ch License # Lic. Class r,, Exp: Date
_
W 6-1407t
Z r-- /aate/)x � Signature of Contractorto
7
J1.— CD OWNER -BUILDER DECLARATION
W W rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
License Law for the following reason:
Z_ ( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ,
co () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner.
rn
Q WORKER'S COMPENSATION DECLARATION
CZ
Ir I hereby affirm under penaltyrf perjury one of the following declarations:
r O () 1 have and will maintain a certificate of consent to self -insure for workers'
':X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q CJ (kJ I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn f— permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carter Policy No.
coo d . ' S?'A't'1 FU'140 046-98 f,JINTrOW7"1.33
J
(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 Californiaz•and agree that if.1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
3 C%ode, I shall forthwith comply with those provisions
t,Date: %Tf' f'� 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, 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 authorize representatives of this City to enter upon
the above-mentioned property for ii6spection purposes~` /Z
LSlgnature (Owner/Agent) (. << "� ZZ-Oate,11)r' " ,-
PERMIT # CONTROL #
BUILDING PERMIT
9X09-241 �
DATE VALUATION $Z20.%.5_Z.4)0 LOT 42.TRACT L� 2 5
!
JOB SITE
ADDRESS 79-040 IMISSION i.%RI E WF&ST
APN 649-Z10-042
OWNER
CONTRACATO�yR1/ DESIGNER / ENGINEER
Y1 ! [1 } t p■ t �,�
F'O..Box 1 r 16
70 295 . e NCHO LA QUIN'fA DR.
LA (_,)U:1NTA CA 92-253
LA QU1f;1'1.-A CA 92253
(760)M-1941. COL# 2°)
USE OF PERMIT
SINGLE FAMILVIDWELLWO
SPD, $":LAN EA, E..0TA, -W.V..1 OR
POOL. PLAN C".l°lkX:K FEE REDUCED 75%FO11 MU[.LT1PL:f 1SSilANC K OF ;
°3A1Lff± PLAN'i'YP£s.
L us d'l. m coms 1'R13v 1'1.Ow .Z 635.00 W.1•
PORC.'•HVIX1710 `1267.00 al.
C3AfbW6fCA12P0ttr 614,00 8F
1LM1l(rl{ FVF SM"110(5
C _!gS'rR.UCn'10N FFE, 101-000-418.000
PilM4 r1l"t~rCK FEE 101. -0%3 -439 -?118
'XfM1,4134,11 U. FEE, 1101-000,4121-000 $105-00
,E1.W11£ZIf;.rg1 Fid 101-000-42E1400 $1610.1
P'1 UNWINC FEE 1014000_11"00 $119.25
S'3'Rryr Q MWYMN TrW, - TtI?:' U) 101-000-241.•000 $22.04
taRAWNC7 F03 1"x31.000.423-000 $20.00
J.N1'RA.3TREJ :"rWi FEE 225 -00 -443 -?42 S4.889.27
rk.R t. IN PLIRL'IC, PL AC 3 $ - 'C LSIC 701 -4)W -255-(W $302. t 3
SUB-TOTAI, C'0NS7Rt)t:"1 ON AND PLAN CHECK
IIESS P EV-PAti)FEES
i'MAL1(➢IN;Id11O',! FEWS D93.1F.NOOir
,,3ce1).Cr
i
RECEIPT,/ j%
/
DATE- %% r (
BY. , _ ,
DATE FINALED
INSPECTOR
17 �;A f
/f i _✓ 1'
f
INSPECTION RECORD
F 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 1 ��
Exhaust Fans
O.K. to Wrap
F.A.U.
_
Framing
Compressor
_
Insulation i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Z
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 Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection`� �r�j ��
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
c
Final
(Utility Notice (Perm)