0001-251 (SATT)LICENSED CONTRACTOR DECLARATION
U) 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.
n License # Lic. Class Date
W In iji:�l)1r 1 +lei.+}.i,'•1iU
r %-.L( 1 !
~o Z ti [ate '/7 Signature of Contractor
O�
U OWNER -BUILDER DECLARATION ,
HWd � I hereby affirm under penalty of perjury that I am exempt from the Contractor's
in 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).
( .) l; as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cr) () I am exempt under Section , B&P.C. for this reason
u�
N Date Signature of Owner
0 N
a Q WORKER'S COMPENSATION DECLARATION
Q I hereby affirm under penalty of perjury one of the following declarations:
A H p () 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
nJ Qperformance of the work for which this permit is issued.
Q (� ( I have and will maintain workers' compensation insurance, as required by
D U Q Sedtion 3700 of the Labor Code, for the performance of the work for which this
i rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
cD 5 Carder 1 A1i41.1 FUJi4."1 Policy No. 1.146t Or"I'lli-ilo,
Q
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' compensation laws of Califor ' d agree that ` should become
sub'ect to �e w,yp�*ers' compensi pprovisi ns of Seddon 00 of the Labor
3 e, lshall fofihwith comply with th, ose p� i! ng, ^�
Date:'fUJ0 Applicant—�—_�
b Warning: Failure to secure Workers' Compensation coverage is unlawf and
shall subject an employer to criminal penalties and civil fines up to $100, 00, 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 foe 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. t agree to comply with all City, and State laws relating to the building
construction, and hereby uthonzeppr sentatives of this City to enter upon
rignatteove-mention�,prope fo'nspec ion pu es.
ure (Owner/Agent) Date /7`'-' Q
BUILDING PERMIT PERMIaIDATE
j (��./, VALUATION S 7.titi, 996.611 LOT %R TRACT 2x%13,15
ico
/' / w
JOB SITE
6g-310 L.isurikm a1aw
APN ayL�•3��-arAl4p
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
41`j'1 vwcCi7o,r 1 Y :1 ;1 17 , 1'7'
r a., a-vi.a♦ ,.•�� r j.. <101 a �Iv:� a
v" 7`C- (t .^r10.1�--T0! U""Y'1�lAT
� l� a�.3v..,. I1.�J •... a �it�
j`f.! 130 i Iti
74-295 i� �liv%.liC� LAI�(� T1� DR.
Ise# Q_k IIIN'I'A CA. 92253
Ln, QUfI+1'i'A CA 92253
('760)"171-? Oil 1 1.13F.!! 1990
USE OF PERMIT
tiaII.�Y.9l, t Akill, 'tr UWE'LLINu
178I'I.iiivi3-E' acir9:1� iii+Fa C�i ifdl.l,i tlElsi,�i�.r; JviU.�.yC,it'
!'Q01_75`,'43 PL.4 N GUECts 1,1:L IULIJLIf ":.fi01l VOR MOLTHILL i:;`il,lANCE, VF
A& . PLAN TIT'aE'
Cvi it.) ON tI. o.
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CIAlZ"/\(3h/C.AtI.iDC➢!!,9' �l_�11,t)[> �`1•
e ,�k aiiinaM e w lu vii i tib ��V�in l�n�IUC-1410N
I"ni.i,�v.rOfs
iERM i"r`EIr;S0it�i�a�Lat�
CQNS'!'It KN'10N FOS 101-O4i0419-OW S.lq�t.y)
I -Ii, N t"Frt~f'Ii PUT-' iftl t)((�- f+1 't j sf RIK'1 44
OE011 Ue1C'AL L 1.3 fr 1t)F !)t3f)-: }. 31ii,
ELiiC".i'►z.1C AL FEE
PLUMBLN43FHJ' iuf-iltii)-1Ii9-000
Fint?NC. N10,1110M M FFF• - tt}';'410 1014)(10-7-1109)
n r 1 0-123- OVO 7 nII)
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•. _
Alia' IN PLIP LK.* PLACES - RESI.0 701.000-255-000 1 P 9`)
Si ryi.•^I�i�'f /11, (fit 1�3ti`'f'I2,1 If'T'3� 1'y !<tN f [�t,AN f'i-)i�C;!:
g,'t,`j7;',"t'z
LESS s'RE-i'a'l.I,'ti fiTTS
'8•0TAL 'PE1704111# ItS 011 ', NOW
�i 4,8'12.,93
RECEIPT
DATE
Y I
DATE FINALED
INSPECTOR
WIN I_MOT 00 0 10_(I�10 01
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- 'd- C -ed
Underground Ducts
Forms & Footings
p'
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final I U- G• C4 1 ATe,
BLOCKWALL APPROVALS
Steel
POOLS a SPAS
Set Backs
Electric Bond
Footings
Main. Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- Gd
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
Q(1
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)
COMMENTS: