SFD (9712-124)L LICENSED CONTRACTOR DECLARATION
1 hereby affiim.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
b:3i�99 E33irfY3::,
Date 7 ,�!-''f'r .!�r if ' ? `..'„�'•
� 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).
( ) 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
performanceof the work for which this permit is issued.
( )' I have and will maintain workers' compensation insurance, as required by
Scion 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 �TAT'O7 ]IFU TO Policy No. '1116.4'+'-GOCtO;1`23
(This section need not be completed if the permit valuation is for $100.00 or less).
() 1 -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 shall forthwith comply with those p.oVlslons.!
Date: q 31 97f Applicant � � • � '���
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 f i ;pecrion`purposes.
Signature (Owner/Agentfit. :«�...
)- Date / 7-7-L
77
BUILDING PERMIT, PERMIT# CONTROL#
DATE ( . VALUATION �d� : LOT' 3 TRACT, n�; y�
';
JOB SITE ''�6JJ_.Jt5 AIJOUJyf.,4 JN S 1, ADC '.rS r
AP N 709-54,M03 "
ADDRESS r
�n... 2.0
OWNER _ a , r 1 r v
CONTRACTOR / DESIGNER / ENGINEER •.
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50445 i TOUNlEAiN S1.-1A00W' tW ' ,_" '
5riW15.h3'0LK1+AiN SHA-001VS P,
L..A, QU.IN`[''A CA. E',`D
LA f,, IUIN A. CA 92253
(760)564-1849 3625,
USE OF
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SS ES
'FUTAL MI)gM IT VC lis 1)07, Now S150597.09
• ' '
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• , rte.
RECEIPT
DATE
BY j""! k -� .
DATE FINALED
INSPECTOR
4
INSPECTION RECORD
r` OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r
BUILDING
APPROVALS
MECHANICAL APPROVALS
'Set Backs
'C
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Z• ,Eq
�,�
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing_
3 . g
��
Compressor
Insulation3—Sim
$
G
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
�7
Drywall -Int. Lath
Final
Final
� �-- �
_
POOLS -SPAS
BLOCKWALL APPROVALS
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
7
Electric Final
Waste Lines=
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
COMMENTS:
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
t,
t
Final
7
Utility Notice (Perm)