SFD (0301-112)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
Date Signature of Contractdr�
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I 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:
( ) 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.
T( ) 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:
Cartier STM, , ;'tTND Policy No. (W643114 l-203
(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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: �' - Applicant ``"`•+ k L �J
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 inspection-putrposes .t
Signature (Owner/Agent) ' Date +
... ..... .. .. � o-1.
PERMIT#
BUILDING PERMIT
DATE VALUATION rA kf 8st.00 LOT5e1
TRACTJOB
SITE'
ADDRESS 7%�MMNON i wwl WEST
APN 649-210-06?
OWNER
CONT�RjyA^.C�TO�R�/DESIGNER
CONTRACTOR
1y
%bP IA.:+Y3,JC:.i6.y�' OEVFdsO�Ci�.�a. �L
y/ENGINEER
r jq1�
h7Xd7.1.\ 01 Y. 1ONSA�C��LL�..AIO
PO BOX 1716
79 295 P. NIM, - 7!,A QMMA DR.
LA Q(rrtaTA CA 92251
LA QL'1i3`P A OA 92253
�760 Y771-1941 CB14 2996
USE OF PERMIT
S OUE FAWLY
SVT) . IVP 57, PLA14 91, P13 MIT DOES'Nar ING.t,.UDE W.00K
WA1,6% x'004 SPA OR DRIVEWAY APPROACH. 7;S% PCO ICITIOX TO I'Z.AN
CHE49 FFR OUZ TO MUL fiP1101SS7UAIMCZ OF''dAMP. f UkN T” ;rPF1
t'1IS! y OU (,"O STRUCTION x.,623.00 OF
TO PIC: FTIP TIO 267.00 8F
0ARAMCAVORT 614,000,W
IATM C:£�ZTP OF ("<ONSTRt� CIT011
M_ 1652.0D
�ppYYry-��j���g��77r ��,,rfy�, �yq.�:S1�
+T�.CaI.LAi.f t6.L YEE HUMA"Ry ..
-
CON19TR TC"I' ON FEE 101 -VICE -41 ii"000 si'v i.00
PLAN CHWK ME 101-000-4- �9-315 $3111.0
F.GHAVICALrFRE 101-000,421-000 SIM00
X='TTI2J:C;AL• FRE 101 -OW -420-010 0162.01
PL:IIIUlUNO !I: 101.0(91.414.000 $1W116
STRONOM0'r)t3t3FRW.-910 101-0043-2111-000
ORAI NO FEE 101.000.423.000 S15160
D V'EI.,0PER IMPACT VEX, $4405.00
Al2#' T T'U01<iC FLACF.v • 'L,�£a' IE 2,70.000-445-00X) snb
UTB-'I;Ci;£AL C%ANM'LiC"1"1014AUIr7 PLAN'CINCK
314,221. !A�
V�SV PIKE-t�� FEN
$0.00
TOTAL ?NOV
S4;2.11.,18
a..,15T
.eYtiJ
RECEIPT
DATE k,
By'-
DAT PINK Q
INSP
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
72 1104 1111�
Slab Grade
_
�� _
Return Air
.�
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap ����/
Framing _
F.A.U.
Compressor
Insulation
- 3-y
Vents
_
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
— —
Final
_
Final -
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines1-2-9--3
Heater Final
Water Piping
�J
Plumbing Final
Plumbing Top Out
Shower Pans
_
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
% - ?j
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring Z
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) - /
COMMENTS: