0108-261 (PLBG)H
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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
42211:1 C36 C42 B W
,Date' r_.,&. Signature of Contractor�ro.•a-
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
pale (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
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.
AM.'AYRICAR ZURICH
(This section need 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: C? r Applicant—
Warning:
pplicant �7.•. -•tae /r �'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal pen`akies 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.
.y gnature (Owner/Agent) mo i) ti•.`�T, f.r: f W Date ;L_-, f'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
.11.- 41 JiVENWA, CARRAffM
7T; -k�a i f113�3
OWNER
CONTRACTxOR / DESIGNER / EN INEER
II1lvV.��,i18:rFI i..'AVd"AV,'.1./�.iL.LLVy 6�131,6':Su'L�r
.Cf.4Y).l/RVV')a`i(l
51.020 AVE, CARRANZA
796 $v, STATE oFf.
I.A. QUIN 1A C k -2253
1011NW C"A. 92543
("9)658-8541 MR 1060
USE OF PERMIT
S1;tAt ER, I•TCtr31 -UP,. STEWn IC ABANDON (1..(W -MOD PIr,O&CT 1401.0-1)
VALUATION _ 1,� ��,Qti 1-4
d.Mb7$a`8 d..�i� t..'�.+M'9 A. '�r�.Aly `..rYFdkV I.r1A L9,V 4✓a.9 .8'iiSE
AjQ�e�a�iAF
�j�;yy�l g,{�'fy y, 'may A.�(^��,y'�Q �j (� {�j�p
" OJaB'•iAP.6Ff FiXi, i743'.Li!T.iY.ihW6i..!•
.
1'ILMAiDIM ITE 101-t 00.419-000 $30,00
o a a
SEP 18 1001
CITOFCQUIN.TA
FYANPT
SUB, t.MAL E30P.13'iRUCT.€L' N ME) PLAK C CTV.
$30.00
IM0.11 PIM. -PAW `E �:i3
S1.110
TOIAI., Y(,KRMfr � JOS DUL NOW
RECEIPT
DATE
BY
D t F LED
INSPECTOR
� INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE'
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion;Air
Roof Deck
Exhaust Fans
O.K, to Wrap
F.A.U.
Framing
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
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 I
: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
Pool Cover
Sewer Connection l-�(n. p 11 S',T
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
Final
Utility Notice (Perm)
Desert Sands Unified School District
NOTICE: THIS DOCUMENT MRNWfION
ON OF PAYMENT
13E DUPLICATED. SCHOOL FACILITY FEES
TO: City of La Quinta DATE:
Department of Community Development
78-105 Calle Estado
La Quinta, CA 92253
iw
E�
This is to certify that W
developer of which is
located at v'"/- moo` within
this District, has paid scho facility fees imposed pursuant to the
authority generated by G vernment Code Sectiot 53080 in the amount of
co eying a total of u e feet of ( ) residential or
( ) industrial/commercial development and that building permits for
this footage in this development myn be issued by your jurisdiction.
9,c r SERT SANDS UNIF ED SCHOOL DISTRICT
White - Building Department • Yellow - Facilities Planning • Pink - Accounting • Gold - Developer
(10)-37