0302-039 (SFD)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 # Lie. Class Exp. Date
1776990 .,p
'Date $�/ `� Signature of Contractor4? XWWfi &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).
( +)' 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. f r this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm :under penalty of perjury one of1the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 ofOhe 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
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 Lll3IMX13 } : 1, %? Policy No. l+iA:N$3 d1t? • 11 Tj
(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 Jorthwith comply with thos pr isiODS.
Date: �'' Applicant 4" .L-0 '
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 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 purposes.
Signature (Owner/Agent) - '�'� Date, z I `_
BUILDING PERMIT PERM#
DATE % y VALUATION } 1p q yry� y * LOT " TRACT
j '1�,. y VAFaJ*m7l P:wD.'na9i .4 ;. N'ti - a4/y� /
C -2)
`r
JOB SITE
ADDRESS fm s" 0WON.C.I�T1-0M �e1317� �
: 77r��fi (k1.1
OWNER
CONTRACTOR/DESIGNER/EN INEER
73.121:�izMD W'AMG4100
1?paly DESIIFEr CA 92260
;(' X 1m-mTfAZI, CA. 9.2260
USE OF PERMIT
'4�I.�:S��i►fAx,�t"I��adi1:��.1�iC3
,
SFO - J.DT 5;4 SEI 0144 PE MY1. DOLS NOT RMC11,11DE, VOO) ,,
SRI& DIX)CKWAUX, OR DRIV9WAY APPROACH.
CUSTOM C:r 40TRUCTION 4=00 SF
Al CfilJC>�►r1't�'1� t 1G<tl0 OF
FS'I t1T'D COs' OF CO-'Nia�RUCTIOI+1
1s i'�"n' W. P S AMARY
(SIDWrRUC;`f'ION P1I.11 2r�� « tat •D Ci �J,ltitz.?�
PLAm tem" Ton 101-000x439-31 8 VON' 09
t i) �Isl:�ltC �. W13 101-000-4-211 -000 S it'6 I.So
R't.9r.:'PRXCAL li'ZE 401 -000-4-20.000
P1,UIt.S1 51Gr, ex 10 -000.419.900 S184.aO
STP 1l OTIM) :YEE - RESID .1.01-000-241.000 {X137
OR At.) IN 0 F RX 101-000-423-10VO $1500
:C)W1_ :1,OK,1R IMPACT ITE, BI,405) 0
ART E:N i't BTACc PLLaACi .'3 RF491C 270-G0D-445N000 U4,33
x'111°$' 1 tYt` 1 CC`a 1 EZ13k;1`1.C�.tvi k�t~i7 1F%,ti%i 'i 31%i°
$.5,001.90
I— � � ; j' •
FE B' 20 zciuj
N. n3 10IM %
RECEIPd:INA� iE cJ.S:f
OA -Pr }J
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings eo
Ducts
v
Slab Grade a,
Return Air
Steel
Combustion Air
Roof Deck S - 5.
Exhaust Fans
O.K. to Wrap _
FramingIC
F.A.U. ,
Compressor
_
Insulation
_ _ _ _Vents
Fireplace P.L. IGrills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
I
Final -- O —
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Test'
—Gas
Electric Final
Waste Lines �?, O
Water Piping �+� '� _
Plumbing Top Out v
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 3 �, �%�
Encapsulation
Gas Piping
Gas Test 4�
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 1 7 7
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit �I
Rough Wiring✓l
Low Voltage Wiring
Fixtures
Maim Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final --
Utility Notice (Perm) s