0001-178 (SFD)LICENSED CONTRACTOR DECLARATION
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
04 LLJW _ - Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
dLO
oZ ✓Date Signature of Contractor
Apr`
J U OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a- 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).
i s � O I am exempt under Section _ B&P.C. for this reason
O N Date r r ' r - Signature of, Owner `
N
0)
a Q WORKER'S COMPENSATION DECLARATION
p C .1.hereby affirm. under penalty of perjury one of the following declarations:
<0 ;f (.) . I have ana 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
m< Q performance of the work for which this permit is issued.
ca U )- I have and will maintain workers' compensation insurance, as required by
O U Q SeZtion 3700 of the Labor Code, for the- performance of the work for which this
Ka; rn H permit is Issued. My workers' compensation' insurance carrier &policy no are x
?,: Z Carrier. ry + 'y Policy No
00 .' ai J A.0 d:.i�u YL '•
�., d,.. �''vdY =ft4'St-.R•'T�a'.S=� t .,,a<. ,.r
M J (This section need not be completed If the permit valuation Is for $100.00 or less).
O I certify that in the perfo{mance of the-.workfor which this permit is issued,
I shall not employ anyaperson;In any manner so as to become subject to the
workers_..compensation'Iaws, of, California, and agree that if I should become
utifect to the workers' compensation provisions of Section 3700 of the Labor
Code I shall forthwith coply with those plro,isions.
Date: /, •' Applicant
c
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for' a permit subject to -the' conditions and restrictions set forth on his
application. 31
1. Each person upon whose behalf this application is made & each person at ;
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton'agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date.of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the
above-mentioned property for.inspectjion purposes. ^
= Signature (Owner/Agent) r 1� t' Date
PERMIT#
BUILDING PERMIT '
`•
`
(t
DATE _%91 • .
s� �r),' VALUATION S126.241.31) LOT i� TRACT 2_%91-
JOB
l,XV567 .VRANCiG iol.rE$.Iti,Y i..i..bUiR
APN
ADDRESS -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
tr.. P11*7 T) ALL-0 {, ....
tu�is)r'r a c�r,4�r:.r�nnar.,�rr 'rxrr
4-333 -H 11iY. I 191110-1
74-.ia + w1 11.1 Sir• 163
- F'At.AfC MEER"!' '. ^:. CA 92260
PALM DESfiN'V CA, 92260
• •
t"�•ctf;t�iS-�
USE OF PERMIT
5F -L V T 19 P. -LAN $L1 - POWIT LCX:5r NOT INc"3 UDE kS.l.00KI11 F"1j..I S OR
i�°i.r C Ce�i��aii2i,Xi.iaON z",G,o,Gi} Jt•
-
C ARACIrEr CAR.PCIRT b$N,4)V SP
4
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ii, l liac1 111.4.1TED CI OSIr' t3 +y�i�r,� a �i><��i �i i
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FIR RMITFEE, MARV
CONS'1'iitrurtuN 11,11-H ?iii -d 00-4.t84K){l �,7: .ik►
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P1;,A N ('FITICK Q P'f? !111 1111(1-�f.2�.� i R 4( 111.Caf.
161-W10-421-000
Lf.{`s(;_1RWALFEE -000-4210-W) gl X1.91.
KU BINU ft+'i 101-000-419-000 $142.00
VVRON(3R1r)Tfl�?�iF"�"f,..R :III V)0 67
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i sllL';?.Civil", M13 101-000.423-M) • � �.t�
L)t'sV&C)PER f!► RACT 1`•P.f:i 3),y<ii.iolj
AKV )N PUBLIC Pl,ACYS - RLSW' 70 -Mi -755-W) ;5.hf7
SI nc }rrn.r, Gt�;n;ST int 3l "! fc►N P:Nyyn ►��,Ar x1 r,k
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T(J•9'AL !'ERMIT FF:K110M. NOW
RECEIPT
DATE
BY ` i i( j
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q
Underground Ducts
Forms & Footings
y'.411
0
Ducts
Slab Grade
AReturn
Air
Steel
Combustion Air
Roof Deck
AQ
Exhaust Fans
O.K to Wrap
—t —ap
F.A.U.
Framing
Insulation
-'s• M., — r1® /y
Compressor
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
POOLS - SPAS
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
1_1 - 00
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Final
Utility Notice (Perm) _IL -00
COMMENTS: