9808-146 (SATT)N U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # LLic. Class Exp.Date
17,10 / B
10ate 7 Signature of Contra or
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt underSection B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(,X) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STATE MIND 137 1 MV5
(This section need not be,completed if the permit valuation is for $100.00 or less).
( ) 1 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 C,aluc,rnia, and ag er a hat -ii I should become
subjec;1e; r ers' com ensation rovisionssof Section 3:'00 of -the Laborde, pith complywith thos provisidnt'.e: ```�� 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, indemnity
& 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 repro es-entatives of this City to enter updW1
the above-mentioned property for iIspection'purpos
I vSignature (Owner/Agent)'v Date' C -
BUILDING PERMIT PERMIT# CONTROL#
DATE VALUATION LOT 40XIIN 146 TRACT'071.2149.16 54
2 3
JOB SIE APN
ADDRESS
tai-.3L.�a sLi'� f i.�3 unit' 6a; lril-SgiY-i4t1:}
O NER CONTRACTOR/DESIGNER/ENGINEER
•�•'•� i'fit.'GEQ'7'r,E:•�It:!!'1liS.l T:nT'!• "AP
//''99 (` dry)
i .V• �A e�-.1.-1\x �1i-. V Ls..�..11 IAL. r:♦ 1. 1 i"l Ii IIC l...f 171 T•L 1lLll.;� yAI
1'.U. BOX € 716 79-215 Ril,NC,'HO LA QU"iN.14X LK.
LA QU1N TA CA 92'253 LIN QUFNI'A CA. 922 53
1141 r.'t11.. 217ci
USE OF PERMIT
SPA - PL:k.tu .if . LOT 4' 34. PERMIT I IKAES NC T `1 NCL1T1) i.i��L()C';k WALT.
OR P )I.. PLAN CAII:?. X. [t?E REDIKTA) 75'1io FOR NIUL'TIPI,iF': ISSUANCE OF
SAME PLAN T'YP'E.
\d C.ONS1I77i,eC"1 ION 2,05100 ,".F
I'c?ttt,tl/N'M,10
A88.00 31:
t1ARA0t,YCA►iPC*T
450.0 Sly
1 S'II NUTED COST OF CONKMI[Z
TION,
;171,2119.10
COKS'1'2 [Yn'JONFEE
101 -MID -418-000
i'r.!1A{ ('EfF.,CR P'EL
10.1, ,.Q(K)-430-319
ZVIEC RAINICA1. i'T U
101-060-421-000
l�s•SO
ELEC11MA: FEE
1Gi.-t?Ob-120 tT(►t)
S�I3st,ott',
f1IAJ 1;l_N* FEE
101-000-419-000
"TT2oNo monON FTY:, - RESID
101,000-.241-000
i RAL11NO it Wil":
101.000-423-M
�2r7.cv:
iNi tAs'muc,€'U,rr.F rEf
22.5-000-443-342
33,7vG,ftS
ART IN PUBLIC PLACEN - Rfisir 101-000-255-000
PADtC'rN 3CTF_C►)✓
AUG 2 81918
TO All PERMIT VMS WE NOW 55,4�dw.5+8
Y OF LA QUINTA
RECEIPT DATA ` G� DATE FINALED INSPECTOR
USPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDNG 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 �j
F.A.U.
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
-orz
Final o-
BL®CKWALL APPROVALS
Steel
PC®LS e SIPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMMMG 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 -16,
Appliances
Final
Final
Utility Notice (Gas) -
ELECTPUCAL APPROVALS
Temp. Power Pale
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
t
FInaI
Utility Notice (Perm)