SFD (0104-263)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I arn'lic'ensed 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
w6x'p. Date
LIKate4k. IZ4_TZ) Signature of Contra N..
OWNER -BUILDER
-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the propdrty, 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
contractor's to cd-nstruct. the project (Sec. .7044, Business, & Professionals
Code). - I I . - .
O .11"lani.,exempt. under Sectioh B&P.C. for this reason
Date' Signature of Owner
WORKER'S COMPENSATION DECLARATION
1hereby affirm under p6nalty of perjury one of the following declarations:
O I have and, will maintain a certificate of consent to -insure for workers'
compensation, as provided for by Section 3700 of thea Labq`rCode, for the
performance of the work for which this permit is issued:
I have and will maintain workers' compensatioinsurance; as required by
Section 3700 of the. Labor Code, for the performance`,16f46 work for which this
permit is issued. My workers' compensation insurance: carrier & policy no. are:
Carrier Polity No.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 Caljiornia, an�,agfree that if I should become
subject to the workers' compe s-otion pirpvigZiris of.Section -700 of., he Labor
Code; shall forthwith hos pravrslo s..
Date. X11 Applic ty=*,�,
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 Applic . ation is hereby made to the Director of Building and Safety
for a perm -it subje I ct to the conditions and restrictions set forth on his
application. -
Each person upon whosebehalf this application is made & each person at
whose request and for whos6 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 applicatio"ri 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.1 have read this application and state that the, above information, is
correct. tagree to comply with all City, and State laws relating to the -building
construction, and hereby authofie"erepresentatives of this City to,6nter upon
above-mentionedthabove-mentionedpro dirty for p"sp,ection purposes.
,Si'gnature (Owner/Agerig" Z,�Date
71�
.BU1LD1NG'PERM1T',.!11 PERMIT#-*
DATE VALUATION LOT TRACT
$236,377.60
JOB SITE
,ADDRESS T
w. s, wo ulvunq yj kv7
OWNER
CONTRACTOR /DESIGNER ER
ASEM''WX COWANY
t
PM.MPOOK,D,WMC�.PMWr!C,'OMPjM4Y
,5140 AVIDIMA ENIGMAS
iWAVENIDAVEMWAS
CARLSBAD 91=18
CAR' SBAD !CA 924008
(76qN,804-6868 CD19, 3376
USE OF PERMIT
4,040LE FAMILY DWEDNG
SPD
WAL'UPOOL4VA OF -APPROACH bRJ%FT',iffAY;
CONSTRUCTION zanao OF
aKRAdrjcARP6wr (sr� A1130,60
RwrJuNrED COW 0.'r COBSITRUM, ON
P.MM Fn SUNK4JRY
CON STRUCTION M 101-000-418,000. sip9m)
PLAN CIMUK FEE 101-000-43.9-316
MECHANICAL Fft 101-000-421-000
1,_000420_000 sw,U
101-000-419-000 SIM50
Q-RA!R40 F90, 101.000-423-000 520-00
ART 114 KJOLIC 1 ids.02 - RME 701-000-25.5-M)
'"M D917031T
'A almu'C', .1. f AW)PLAN (4
$4,4W,. -74
I M93 PRE_�PAJD MIMS
.7 0.00
APR 2 4TM. x x, in, 'i --r Frm Dxw now
$3,744.74
CITY N'tk'OUINTA
FINANCE DEPT
RECEIPT
DATE
-Int
DA
NSP CTQR
!A
INSPECTION RECQRD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_
Return Air
Steel
Roof Deck
_ _
//
Combustion Air
Exhaust Fans
Framino
Compressor
insulation
i�
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_�
o
POOLS - SPAS
BLOCKWAL�.
A PROVALS
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
Gas Test
Electric Final
Waste Lines
_
; ��J/��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
;
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
? %1J //�'(i
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condult
Rough Wiring
Low Voltage Wiring
j
Fixtures
I
Main Service
Sub Panels
f
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
i
Utility Notice (Perm)
/