0001-258 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- 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.
Cj License # Lic. Class Exp., Date
0 1674074
077/3 1;20i
LU
cZ ti /late^ �/,122Signature of Contra oxo
co 0' t.
r` I— OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contra tor's
U) 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).
Cf) O I am exempt under Section B&RC. for this reason
O N Date Signature of Owner
d Q WORKER'S COMPENSATION DECLARATION
j Z I hereby affirm under penalty of perjury one of the following declarations:
H O 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
nJQ performance of the work for which this permit is issued.
Q CJ I have and will maintain workers' compensation insurance, as required by
j U Q S n 3700 of the Labor Code, for the performance of the work for which this
i rn I— permit is issued. My workers' compensation insurance carder & policy no. are:
,It Z. Carrier eKr•rt .�.rPolicy No.
A i 3l•" ,m/.i; 1 .114 1111 : -/ti 3�...•
(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 Californiatd agree that if I become
subject to the workers' compensation provisions of Sectio 00 the Labor
C90e-I sttpll forthwith comply with those provisions
Applicant
Warning: Failure to secure Workers' Compe etion coverage iS"Unla %t 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 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 autDortze,rlepresentatives of this City to enter upon
the above-mentioned property for Inspe purposes.
Signature (Owner/Agent)- Date L.! "�0iJ/to
BUILDING PERMIT PERMIT#
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DATE /0 VALUATION $1,413"016.60 LOT ug TRACT 2']9'3`)
1OB SIT'
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PN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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i..AQUI N'I'A (2A 9225-i
1760"07#-;9.11 (�"_I�i�T./;� ?991+
USE OF PERMIT
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RECEIPT
DATE
BY/DATE
J
FINALED
INSPECTOR
,.
I TJ . ' F'' 0 �� ? ,i ;gip `-� R; — r (01 )
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING.
APPROVALS
MECHANICAL APPROVALS
Set Backs
-:715f
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
9-
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap—
Z-41*0
F.A.U.
Framing
Qa
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 - SPAS
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
<24 AgL<=
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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) v Q
COMMENTS: