9808-142 (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
cel W Professionals Code, and my License is in full force and effect.
=) ch License # Lig.Glass ,F�cp. Date
CYLU
1 Ap
r` Z ti vdate Signature of Cont?actoc
00�.
r- U OWNER -BUILDER DECLARATION
HCL LU r— I hereby affirm under penalty of perjury that I am exempt from the Contractor'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 offeredfor
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).
C") O I am exempt under Section , B&P.C. for this reason
LO
O N Date Signature of Owner
rn
(L Z WORKER'S COMPENSATION DECLARATION
It O I= I hereby affirm under penalty of perjury one of the following declarations:
U') H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W UL compensation, as provided for by Section 3700 of the Labor Code, for the
O J JQ 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 Q Section 3100 of the Labor Code, for the performance of the work for which this
0: rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
le Z Carrier Policy No.
ob :) -
C1TATI�, Fmr) 1171095
(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_, nanner so as to becpaije subject to the
workers' compensation laws of Californ�l, and agree thaf if 1 s ould become
subject to theA
rkers' compensi3tion pr visions Section 3700 of the Labor
'3 Copde,eF ,gith comply with those ovisiofls.:'yDate: SJi Applicant �- L
Warning: Failure to secure Workers' Compensation coverage is unlawf I 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 permitissued 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 becomesnull 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 nd State laws relating to the building
construction, and Thereby. authorize reprees�entatives of this City to enter upon
thw> bove-mentioned propein01
or in
spectid pure es.11-
N , - �,/� e,
•Signature (Owner/Agent) Date /�`
BUILDINGPERMIT PERMIT.# - CONTROL#
DATE VALUATION LOT ` P' 1411 TRACT
� 19
1%
�• Gj !?tai .°!Fi'l.gfl S(! i .A . 1 V
JOB SITE
APN
ADDRESS 49-265 4 -,ANI I A DAljiVE
64-9-380-00.5
OWNER
CONTRACTOR / DESIGNER / ENGINEER
a.. �. t T
/.1.. 1,•a.+I.,IY.L.J.r•„.1 �i l.tas'
:`;PA:� K. ` C �1^�� 11tS"� Ujr, r 0111
\. I . 11
B.X 17ICt
79-2ty51L'al40.10 LA OUIN�IA. DR.
LA.( 1ANI''A CA �Q?53
t ntjlll:NTA. (>A 92251
r7Cf1►T74 !9tf C`13Li� 2.996
USE OF PERMIT
'ANGLE, PANUlr ALTA ;I- ED
Z,Wr\ - PLAN Al LOT fi JU, 1°LI2N 1` 1.J4.al<sS NOT INCL -U01! BLOCK WALL
OR POOL.
CUST01M CONSTRUCTION 1,975.1010 Sr"
PORCH/PATIO 00100 8F
.n'*T1!k 4&T9i,D COST OF COM"ITTi UCB'IC,`N
16w.i►ti1.1it`,
PFU Mi> T ti KE NUINIlitARY
ID NSTRU("1•hJ'N F 1, 101 -OW -41 K,f;'(Jt1 8ti i -fes
Pt AN01FFCk FEE 10141100-439-318
NIECHANIQNL FEE 101-00-421-000 �1115.r�L�
M- K,'TRICA1.51i1s 10t-0004204)00
PLVA4BING FEE 10tAW-419-000 SI55.2s
STRONG 1`440'f ION FIT - TU'SJD !(J) -000-2-1J [)!?tl :. '., $lei s41
OFUU)ING FEE 101-000-423-000
101-000-423-000 $20.rk1
iNT, KA:5TR( CTURE t:ER 225-0W-44'3-342 5,3.666.75
ART IAN PURLI , PLACES - Ry..`Itt� 7f11 Q(3tJ-i54-41(1{ $tfia,4�j
-1TY1•n!, CONS-FRI.A-MON AND Kr1N CH1'rtr:
LESS PRI. -PAID YIELS
S0.00
RECEIPTDT
BY
DATE FINALED
INSPECTOR
NSPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULMNG APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 7Y 5f V
Return Air
Steel
Combustion Air
Roof Deck Z -
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation G 9-7 ;ETOZ'
vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath — 3- I,G(
Drywall - Int. Lath —
Final
Final
13LOCI WALLL APPROVALS
POOLLS 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
PLUM NG 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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTi RECALL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 3�