9802-054 (SATT)CO
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LICENSED CONTRACTOR DECLARATION
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 -
07401.l f3
Date r"' T f " 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.
1',1`113 i UND 137 10( 97
(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 toithe workers' compensation provisions of'Section 3700 of -the Labor
CodQ; Ifshall fgrthwith comply with those pr�•.vislo`ns.
Date:: , C Applicants" F
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, 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
coAtruction, and hereby authorize -rep enta fives, f this City to enter upon
th9 above-mentioned property,fdr inspectio ,purposes. r `
y Signature (Owner/AgentDate4r _.
PERMIT
BUILDING PERMIT' PERMIT# CONTRO®L#�9
DATE VALUATION '��7>) '��y �� LOT TRACT
G
h')/,;, G825
�
JOB SITE r
ADDRESS $�1'i-V.3)3 Q-tk Si'.l *A DIr'.I E
APN 649-3N04iO3
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Citi a r)) ►°C f� nt� 'r is t� 1r.r
i P.O. Ivil1: 1716
70145 kiVNCHO LA QU11' TA DR.
LA (x)11 NFI-A CA 1)"C"'5 s
LA Q01NIA 'A 5ti2125 t
i'M?i7l.i-fff-11 f"i�LY �1N1
USE OF PERMIT
1^ f1
d:d71 +15, t,AS i'A!'i.7kN 6. i'LAN0, tJf' t`f1t S�'1.t)fJ4I;SL�
itis/o 11A)h fM[fLTIPIA- 13Sl. ANCE O SAM I D
APR
0 8 199$ 1
U.131 ,�1 Cx. N-3TRUC—TION �,+.r .��0 8
is:04) sF
CDT ' 0
F LA 0 1NT
t?;ST 6IVIAUD CMT OF f'01`3"s'TR !C 0,,,4
i"E.RNUTI' FEW SdAti'iNIARV
031-45T N i'Ev'
PL A -N CIF'0`:. F U_; I! 1_ Q !-ft0il-=l i�� i 1+ $ 3 k1 ? 3
NI -(M.
FL9 IANICAf, i'f'sts 101-00-0-421 •(x'1(1
a, Ek_`['RICAL FFE 101, -0(* -4 0 000 3LkS 6
PLU1v B114G FEL 101 -OW -1119-000 S 16 t .25
IV I ON;31vi> > Tf V t. F± 1 f�1r `tg� ,(i)1-{1f1t1..�,i 1-Q11C► $17. !
(_414 AD114G 11,11% 101-E►fY"23 J00 P x'20 (!!l
(NFKA8TRt C'ft*ti FEE 22-5,000-443-342
AWC tN PU13JAC" eLlwvS h'!'SilN.itla-�fk1-? !J(iU $17'3.1^
S1 I -R- '(-)T A 1'0N'tt;f°r70iN AN D 1 -Ii C K
LESS tai 13-11"VLY FLE,
!CJTAL P+kiF.RNOT FFLS ItiUEN<)%V
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSF'ECTIOO N I�ECORL�
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BOLDING
APPROVALS
MECHAN6 CAL APPROVALS
Set Backs
—
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K to Wrap
3/. 9
LIQ
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
-• �(• Y%
(.G1
Drywall - Int. Lath
Final
Final
BLOCKQf ALLY APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMSW(3 APPROVALS
Gas Test
Electric Final
Waste Lines
72-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
—�
Pool Cover
Sewer Connection
('7V
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) G -
ELEC TGA AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service "
Sub Panels
Exterior Receptacles
G.F.I. �—
Smoke Delsctors
Temp. Use of Power
r
Final—
U014 NO ice (Parm) l �
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