0012-099 (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 # Lic. Class' Exp. Date
bDate /J TI/ Signature of
OWNER -BUILDER DECLARATION I
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).
O I am exempt under SectionB&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, i,5 --provided for by Section 3700 of the Labor Code, for -the
.performance of the work for which this permit is issued. ' f
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 Policy NO.`:, re
0014DEN MOLE TNR.° ASCM4060 G2 F:
(This section nee& 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 l should become
subject to -the workers, compensation provisions of Section .3700 of the_ Labor
Code, I sh II fgrtliwith comply with those provisions.
Date:..,��,s:��r i/ Applicant
Date:
r k
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and'civil fines up to $1.00,000, in
addition to the cost of compensation, damages'as provided -for in Section'3706
of the Labor Code; interest,and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a ,permit subject to the conditions 'and .'restrictions set' forth on his
application.:
1. Each.person upon whose behalf this application.is made & each person at
whose request and for whose benefit work is performed under or pursuantA .
any.permit issued.as a result of this applicaton agrees to, & shall, indemnify, '
& hold; harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a.result of this application becomes null and void'if
work is not commenced within 180 'days from date• of issuance. of such
permit, or cessation of work for 180 days will•subject permit to cancellation.
I certify that I have read this application and state that the above information is `
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
ignature (Owner/Agent)Date ` +
•
BUILDING, PERMIT PERMIT#
DATE VALUATION LOT . TRACT
23773.5
JOB SITE
APN
ADDRESS �""�'1?t,� 1r�����
' �if1�►-(AI1�?-0�tfi
OWNER
CONTRACTOR/DESIGNER/ ENGINEER
,
STAi<.l'a.El•IT.0 lDillnll'.',5 LEC,
1
PO BOX S 140
1535 30: -V.17,1 . #200 -
avpm,t'BEACH CA 92662. •
StWB'R k l'ed l? O CA 92408
.
(S )3gt-C(}07 CBL#f 2,120
USE OF PERMIT
stl1woy.ze]Fri�y��•��diy.3��°%(�7/�
�y-n7p'�.$rp.��gr�� r p y��/+y �y�yyg-
bP°17-fJAN 2B �;.ciT' 2- ?1;1��d11T'1�L�.t;S �ly/ .1fVR.)a �C 6Jl'+
0")pfdWA1..f;.f,St?OOUDYtWfM- A,`t APPWA.2'H,75 Vie, PLAN CIECK REV.
REDUCTION FOR MULT1PIX ISSUA14C E OF VJ .Vlt P1,A:N MR,
TRACT COWS"TRUCTWV U31100 sy
PORC41WPATto 4$:00 SP
:�'�►3"I' .4'Tl+ li3 COST {31! �'tit'a�' ?�:�ld.,`:I�OR
il1i�
PERKrr ME, 901AKW
colanx C 1vla ; 101"000.410-000 91106.00
FLAN CHECK FU '101-000-439-318 $144.60
MEC11AIUCALfUZ 101-9M421-000
10) -OW 420-000. $11x.74
XaLISM10 RE
'STRONG MOTION VEF • RES1O 101 f)(0141- 000 �11.R7
ORADI1' O FRE 101-OOLI-423-000
DEVELOPER PER i5V3PACT 792, 01,4Ct7:fJl1
s1m =.FSi:. CommfiuC?1'�i�.115' �>.AF•J��:���'?FttLA1i���[yyCv�'S�7FZ�CX
$3,i1Qw.f91/3�
y�rl
r4' •.6ei' 5. .i-.i\.iu°.S".t'17') �.a, .•iG`wl'
,.
i
TOTUt IT F% SNOW -1,
JAN 1`8
�T 6 �u _
. .
RECEIPT
DATE- `
1BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
\
6y.
leir_%G
Ducts
Return Air
Steel
3 �b
Combustion Air
Roof Deck
O.K. to Wrap
,
_ _Z! _�
FOS-
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
Fireplace P.L.
/
( a�
/
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath/
Drywall - Int. Lath_��
_
6'
Final
Final-2� a-! CG_!i
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-�
--
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
X22,
C�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) (J(
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)