0001-256 (SATT)LICENSED CONTRACTOR DECLARATION
Cl) I hereby affirm under penalty of perjury that I am licensed under provisions of
H 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.
� License # Lic. Class xp.. Date
O
IO
6740-14 ' is f G �r'air iit
cZ r-- v ate�Signature of Contra�cQ,
O r` 07
r- U 0 OWNER -BUILDER DECLARATION
LLILU I hereby affirm under penalty of perjury that I am exempt from the Contractor s
rA 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):
( ) I am exempt under Section , B&RC: for this reason
►n
N Date Signature of Owner
ON
O
d Q WORKER'S COMPENSATION DECLARATION
o 2 Z I hereby affirm under penalty of perjury one of the following declarations:
H p () 1 have and will maintain a certificate of consent to self insure for workers'
X W tL compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () ( I have and will maintain workers' compensation insurance, as required by
O U tio
Q Se n 3700 of the Labor Code, for the performance of the work for which this
0- a0i H permit is issued. My workers' compensation insurance carrier & policy no. are:
I -Z
ob j Carne[ :'fA't't,: C1?tdt? Policy No. fi4F f4gla73 xf:
J (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
3 subject to the workers' compensatioji,-11"7 lons,of'SeNon 3700 of the Labor
Coc4e; I sh II forthwith comply with -those pr6yisi6ns.
e:
!7-1,a - Applicant
Warning: Failure to secure Workers' Compensation coverage is u lawful and
shall subject an employer to criminal penalties and civil fines up to $ 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 permitsubject 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 prope�y-f6 ' spec ' n purposes.
ignature (Owner/Agent), Date" /'1f C7
,�1 -
/ BUILDING PERMIT PERMI'"NJl-z.,
DATE I !)/] VALUATION $173,196.6,0 LOT }`_1 TRACT ?7f,135
JOB SITE
ADDRESS 48-230 l [lull Af6 DUR'1+ APN G►iF-:iJtE-OYi
OWNER CONTRACTOR / DESIGNER/ ENGINEER
.jJ 1) SEj?,'j' I E o`i t'CltI,T11111'?0:
.
0 BOX 1716 '0495 RLANC: i(_'; LA QUINT& E)L
LA t>il_llNTA. t_'t•1. 1),1253 1.A i)UINV i'A LAN. 02""%3
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RECEIPT I DATE
DATE FINALED I INSPECTOR
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AR1 IN i?1it3t..11.; VI.ACV8-.Rfi3ft;
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$188.99
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RECEIPT I DATE
DATE FINALED I INSPECTOR
r73,o'.()o
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backszz
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
.-
Exhaust Fans
O.K. to Wrap
F.A.U. 0.
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
BLOCKWAL
L APPROVALS
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
, GCl
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer LateralPool
Cover
Sewer Connection
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)