0001-260 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
G :5 M License # Lic. Class Exp.; Date
r- 0 � uTjG74 1n C1 _I')')(
I LU~ Z r- /Date-� ��''�%r� Signature of Contractor—
co011� �T t —
JU 0 OWNER -11:111.11111
H aW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
M () I am exempt under Section—, B&P.C. for this reason
LO
N Date Signature of Owner
O�
a Q WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
n H O {) 1 have and will maintain a certificate of consent to self -insure for workers'
K W �= compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is issued.
n Q U ) have and will maintain workers' compensation insurance, as required by
] ()Q Se n 3700 of the Labor Code, for the performance of the work for which this
LLO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CartierPolicy No.
ao :5a 'iii E u J) 01, :t1
� d
g (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 Calif?pa,,
d agree that if I should become
3 subject to the workers' compensat�n prows! ns of -Section 3700 of the Labor
Cod I sl1&ll fd'rthwith comply with those
Dia
f 'ions. %
e: ^ !� 119, � Applicant �` `--
-r -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,600, in
addition to the cost of compensation, damages as provided ;forin Section 3706
s 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 Rerformed 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 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 prPperty forinspectioLpurposs.
signature (Owner/Age%ntL. r Date
t
PERMIT #
P
BUILDINGPERMITDT� 0111)(00-260TRACT �, .,
DATE ,.,y(�' VALUATION
ADDRESS 48-1 JOB SITE Iii CMF FUA& DRIVE APN 649- ,30-604
OWNER CONTRACTOR / DESIGNER / ENGINEER
•+fi n r, Ep -r ' ri o .n: 1 r r1' -A T c n� j I'll r If rrr nt
� aJ itiv��k�l V1.: r1'. i.,t.ie '1�'uz �i, ., �.,�. .��. .-xa\....1•e ,t�.
110 BOX -.1 i 0 LA(fi NTAj t.
LA 111 IN1-A CA 92253 LA i UIN'I'A i_'A 92.4 it
4 760177 1- 19-41
USE
;ilFo 0,;t*s; pi AA' lk-irlXZN-1 i' El dES NOT R40U :LY.}S 4i..00K, WALLS OR
l'4Ji7L.75''o
PLAN kAit: K t~' L REDUCTION VOR!!lilt, (APLs t$51lAI`r� t (,'iL
NAME PLAN 't'YRUI
CUSTOM M CriNSiii 3 i��: i It i i i.47S.i fi; SI
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RECEIPT I DATE
1(7N AN.I) PI,11 N (:'f`1EVt:'
i'4?' AT, 011F. NOW
DATE FINALED J INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANV CAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
- e --C
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
BLOCKWALL APPROVALS
POOLS o SPAS
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
- - C -Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
7.Pool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
C'Q
Appliances
Final
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) A7'' S
COMMENTS: