9808-144 (SATT)LICENSED CONTRACTOR DECLARATION
U) 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
04 W Professionals Code, and my License is in full force and effect.
G d ch License # Lic. Class Exp. Date
ti i�
LO
W �ii7!{rTi�1
cZ r-- ,Date Signature of ContractorS.__
O r•
rU coo OWNER -BUILDER DECLARATION`
W d 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 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).
Cl) () I am exempt under Section , B&RC. for this reason
LO
O N Date Signature of Owner
0)d Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
U') H O O 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O Qperformance of the work for which this permit is issued.
M Q U Os I have and will maintain workers' compensation insurance, as required by
OU Q section 3700 of the Labor Code, for the performance of the work for which this
Il In
0) H permit is issued. My workers' compensation insurance carrier & policy no, are:
It Z Carry Policy No.
.cb 5
Q -`_ T K f i. rrmp 109,t
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' compen ation laws of CaUfo�nia, an er e -that if I should•ber�ome
Su 'ect to e w rkers' compensation proviI
s f Section 3700 1of the J or
3 de, Irshal ith comply withithos6.p n . ti
ate: � / � Applicant
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 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 re esentatives of this City to en r upon
the above-mentioned pr perty for ins a ion purposes./�
/Signature (Owner/Agent Date d
BUILDINGPERMIT PERMIT" CONTROL#
DATE VALUATION LOT TRACT % 1
i
J � $ 71,249.110 522.i' -•
JOB SITE
APN
ADDRESS 4XZ95 C.AS I( rA, D1K,1,'E' ie.
(49- 1490-005
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'r ?-, 'w:uR`I :sr'..'j l.t ;.�a S� )�
c;'..V C f:'',"dU`;;ti'�l
11.0. BOX 1 716
71Q93 ", NC -IO LA WINTA DR.
LA()..iRNM A CA 92253
1,A QU1NTA CA 1)1'253
USE OF PERMIT
IPtc �l.i; h'A M,YI T cl fell)
SFA •• NlakN LS , LOT T r 52. Pi �'"W :' DOES 140T INCLUDE BL0CK 1111AII
U�t iK:6(.al,, t"�LAt'd c:kfF;(;K t�t�F's R6.t";UUL:L:1:> 75°ut'��t� f�tl)1,7'iPL� 1S..iilA.t�IC;i�. ()l�
SAME: PLAN `I'YPF:.
(;L)5'1*fit$(;?C.T.NSTRUCTION :3103.00 31
(',ARA6:f9C'ARP0KT 4g0.0U St'
d�.'sITIMA!'Lr'D COST OFCONSTRUCTION
171.2"49,1W
PUt1 i' FEZ SUMMARY
CONSTRUCTION FRE 101-00041.8-000 �£35►1.:tJ
PL AN (71[NCIC. FETE 1101.001q -1N-318 8IS-t.'24
MI CTIANICAL Fly; 101-000-423.00() S9`l.
ELECTRIC AL T -fly 1l}1-i}t?0-42(3-i}I1G %118.36
N1,t W.413C1 FEE 101 -OW -419-000 5�161:'ti5
,.TROD`(:; NIOTIOAI Fl^rs . RtS11D 101-000-241-000
GRAI)INQ b'FE, 101-000-423-M0 $200)
CN'1,RA3Ti'(Q": IRE Fr t, 25-WQ-441}- 342 $3.796.85
ART fN 141AYAC PLACES - RE,41[C 1111£000-2.55410 121
,
f.
111-7CYTA : CCN'z;iTX T!0N .alM1 D t'VA1v
LESS PNEP-PIA4131`N:ES
U'Pro
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3 4I)II31fi;
AUG 2 90
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RECEIPT
DA `
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BMMMG
APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- --�
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
$
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor - ^r_1 91cr
Insulation
Z 2 •Zo -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
—I
Drywall - Int. Lath
Final
Final -
BLOCKPfi ALS L APPROVALS
POOILS o SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLU6lf BNB 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) 17--77-77 IL
ELECTMCAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detector
Temp. Use of Power
Flnal
Utility Notice (Perm)
COMMl MTS: