9802-048 (SATT)I-
_N
Cf)
O 5 M
d r
LU
C Z r.-
CPOOO
CD
UJ LU
Z
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
u, %J07-1 Li 76 i %??
Date a", �' •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
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 Policy No.
STA TE Epi ND, .13'11)95`.)7
(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 th5jt-i, should become
subject to the wpprkers' compensation .prove ons of Section 3700 of the Labor
Codell folih ith comply with those prQi *ons" f y'
Date: S, ' L Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful Vhd
shall subject an employer to criminal penalties and civil fines up to $100,006, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's. fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read thisapplication and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
co struction, and hereby authorize representatives of this City to enter pon
tO above-mentioned property'fCr inspection•purpo S.
v Signature (Owner/Ag eht}-- f / Date'
BUILDINGPERMIT PERMIT# - CONTROL#
DATEr VALUATION , LOT TRACT Q
A
JOB SITE
ADDRESS d�a'•����"k� JII 115
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'(•11 it ;ti•17t>•r r•�T:tr�r� r- i�a•xl;nrf
ST,
tsar-,� s• �r♦�TUi lf.;.1�7�7
r, :1Je11.,} .... t.11'�.i ,•:.e. ,,�.t, J
i' o. i33OX ) : i6
a3.Etiv lt.i::r Liv i "tSlidTA DR.
I..rl QU[II1TA CA►,, ."'3
LA I!, 1AMI'A {,:A 9 ?-11
_1
I"7(iil);7I:I�1�11 {'1St.df "':pyit
USE OF PERMIT
,
i�1Ji'1' :5�, +1.i 9 Ad'1_iUv !1. r'[ 'uv +;tit `F, iii �k'i'filiY s►I' a 1: lif 11i1C 1�1�
7-�'/o F•C)1[ ,NWLTIPi.l� 1,`i::;i./F�Nt,i Ut `iAt�11 F'1.t1N'i' t"171 , �"
PAI
1,975.00 tF
lytilt4AVI'ATIO E�r3.fry Sr OFLA
QUINTA
,CITY
(.1ARA( ').H;AJARPOKI,165.00 tit
�',,'$ 4 S.;t��'�'�'�t'� »:il'ST �.T� �'�14'S.e :ti r;.:'i•iisr�`
B.f1r� �%w �..`:c9
PERM1114 VICE, MMAI ARV
CONS R 1C 71{ N FEE, 101 -of)()- I "s ii-(NAf Sl3h t r�t1
F 1..1\31 t 4lL C:Iti. r!'i►3 1 fl?-fit►fJ ? 4''r :t 1 R S 170.74.
X0,1.1A1 ICAL 1,14: :t)! •Cr(1t1 a^ (-(►OI) $ J.ti$.{til
Ef.,C:C•.eRICAL VG1 I.t).i-ttt?�-i° dlail(Dti �c13`.�,9s
PLL INIBI'MO VUF. 101-010-4119-000 $155.2.5
`• RO O14tt;,rt{.-iNR!E-itr;llf► 101.000-7,a!AN' J0 1,Il659
c:[zru)INr FFNI 10E -f)()1)-421-000 S120.60
1XFRA3Tk1.1>:."d'1J1XI VhE Zti)-Ui)l1-J=1?� 6<l� Q�,ErtrFi.'Jr
ARTIN PO f„ 1CPi.F+fJ1_S - RE'Sff,' 162.40
802-110a'AL �:�,'t YN.IZ1'is IK"110N _ Nit) Ill AN 0 tE C
.D.5 101; t J'Nff FFE
;1
ryR
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
SWLDING
APPROVALS
MECHAN1 CAL APPROVALS
Set Backs
'/ - of
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
- 1 . 49 101
foe
F.A.U. -
Framing
Compressor
Insulation
•2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Farts & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
-
Final ti
Final
SLOCKWAL L APPROVALS
POOLS a SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBENG 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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
-! .
Appliances
Final
Final - jr Pj
Utility Notice (Gas)
ELLEC7r= L APPROVALS
Temp. Pourer Pole
Underground -Conduit
Rough Wiring
Low Voltage Wiring
Futures
Main Service _
Sub Panels
E)derior Receptacles
G.F.I. _
Smoke Detectors
Temp. Use of Power
tJtllity Idolice -Perm)_ L(J=� c� `(i M
COMMENTS: