0003-179 (SFD)" w a•
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
74380 , . I 12/31120(
Date L:� } Signature of Contractor,
�--./ �
` 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).
( ) 1, as owner of'the property" am•exclusively'contracting with licensed
contractors to.construct'tFie 'project (Sec. 7044, Business & Professionals
Code). r I r
O . I am exempt under Section B&P.C. for this reason
Date "' Signature of Owrier r�
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 4or by Section 3700 of the 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 lPolicy No. •
`tA���v.v3 '<9
(This section need not• be completed if the permit .valuation Is for $100+00 or less):
O I certify that in the performance,-ofthe, work for;which`th spermit is issued;
I shall not•employ any. personn,'any manner so as.to become subject to the
workers' compensation lawsof•:.Californ6,'and agree that if I should become
subject to.the workers' compensation provisions of Section_ 3700 -of the Labor
Code, I sha11 forthwith comply with those provisions." `, •
:.,Vate:•� ' Applicant r 1 x ,m J e
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 purposes.
ignature (Owner/Agent)' ! = <' `- Date
PERMIT #
BUILDING PERMIT' A
%,,
DATE ) Jam/ f VALUATION 1�!J�(��� LOT Q TRACTStliy) (.
/ .
JOB SITE
ADDRESS 70- 187 AJ0kNbNGo GLOI V COURTAPN
" C➢4WOU 005
OWNER ,Zr
CONTRACTOR /DESIGNER/ ENGINEER
1
Y :01thIN t (' C'� .4r.
A.Lii.7 :;.•t"11�4 t� �l/i�4 -
{{!•'lY'7i T)
♦1 tJ4�.i./. L.I
'74-3331•t'Z; Y 1 H STE 103
4-333 HXVY 1 i 1 S r iOz
PA"1. Y1 LEMME' CA 92260
PA.i..`IVi DUSET.07 -,.CA 92260
rr1;4ti'6S1.Jgc CW, 5028
USE OF PERMIT
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SSINO'LH VAMILY DWELLING
SM -LOT 20 PLK14 3BR - tt1~ (MIT DORS NOT TNG DUDE &LOCKMOLS CYR ;
TIRAC'Y CONSTIRUCTION i,`4,'3{1.? (i si
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1 7,014S."00
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CONSTFUFCTION f~•.cr 101 -OM -418 -Wig
PT.#1N C:FiE04 -FRI 101-000-439-3.19 USZ81
CIL rICT[<.aCPCI.Fa- , 101-000420-000
t•/1_s~tNIBI O faEE 1014)00-4 19-000 316L25
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AWV 1N .PUBt;W PLAGt✓'S -.CkC:,` L 1x11-0001 253-{(() $92.6:1
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19
I
RECEIPT
DATE
BY p�1�/ { \
DATE FINALED
INSPECTOR
OPERATION j
DATE
INSPECTOR
OPERATION.
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
"ji
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
--L
Compressor
Insulation
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
Z - 1- E
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)
COMMENTS: