0001-248 (SATT)CO
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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 # Lic. Class Exp., Date
O1 It�/r 1 B 6I/31;•j
V/ !
Date � % , (%�`• Signature of Contractor � �` � ._•_ _ -
OWNER -BUILDER
I hereby affirm under penalty of perjury that I am exempt from the Contrac�es
License Law for the following reason: 1
( ) 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&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I 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.
) I have and will maintain workers; compensation insurance, as required by
Sebtion 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.
t• -r 9•r nl I1,1Y Ir /
.), f'l.l,.i / ;A D 016,-�jl 1, f..
(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
subject to the workers' compensation pp.ws ns of n 3700 of the Labor
Code, I sh II f ihwith comply with th/os�'prows ' 1 --
Date: r+ Applicant—!.�"
Warning: Failure to secure Workers' Co ensation coverage is unla 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 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 hereb� rize representatives of this City to enter upon
the above-mentioned property fo inspection purposes.
S' nature (Owner/Ane'W Date a�om_?�
PERMIT #
jjj,,, BUILDING PERMIT offtii-.took
DATE,ry �v VALUATION S37.3-196.60 LOT 'r i TRACT rYT
rl' (/
ADDRESS �it�• J:�ti t.ii E fi tijtl �1RA !. JOB SITE APN aysa••,f � ()(i�
OWNER ` 1 f CONTRACTOR / DESIGNER / ENGINEER
TYL.
i,,(-)i+ii f ilt:i 7 t X95 ftk'NICH.0 LA +iJ1iVTli DR.
1..A Q1.JU0i 1-A CA 922153 LA C;A 02,253
USE OF PERMIT
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L01'115 5 PLAN i -i'a; it l` f.ADkS Nil l iNCLi E"F B1..00K V.LkU4L+I(
1100L ' Yj' )PLAN CHECK I�Eki RELA("1'ION VOK A4t.lt,'ii'tl/L1; i:!iSUAlv(:I'; 00
SANiF. PLAN TYPE
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18t5.00 4
ci,�ttltt�Ui;tVU'+?ts'1'
450.09 S
L•vw0%9 'i'R: r//�5Y \i. I"•P1A`i"i'!►i E!•T➢llllt
tii/A11V1,A.f.A�Y %..'LY�/. t,!Y' ";o-AL\Y,
iYEL;—K1%-fii vi -,L INUMAM-tiita.Y
,_'CICS t'If LIC1'ION FEE 101-000-4 18-wil
t7f, AN r"dR?('K. 1-1'IP, ifl!-11()(i-.!i i -ilh'; $1$S 5d
.t•el,t,.li� 9,14 •r IG' Ly'0•.,''1 L'U`) gs►
A14 Al"r 0,IU. ,. 11 1 ' 1 mylr,.
iii. hL;' RJCAI.I las ]Cil. -OW -420-000
"LUMBINO 1014.0i -119 -ft.)
•rl r�r�*t<"; ��: rt tc �w 1.rr, 17T.'Sn0 10 141110-141- (1041 4.17 t"
M. A.' tol 0010 1 t1UC1 ':SU.ivtr
C.)iiV1.�l,•✓i'ta2. 1t4tfi'e\l.''I` 4'i�!: Y+I,:N.'l,lNi
Wl' IN -, • .i13L
RECEIPT I DATE
11�'1,gf.4`f}'V1?Zt1("i'lf-)1i Aed))f�f,/1.3!1!'iiH'ClC
'11'0)TAi, PERNIVA' FEES Mile, NOW
DATE FINALED ]INSPECTOR
t'(1 fifl
IPJ �=.FFZr"0fl110,`, I 1,i1A 4
OPERATION
I DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDWG
APPROVALS
MECHANICAL APPROVALS
Set Backs
Ce
Underground Ducts
Forms & Footings
Cp-
Ducts
Slab Grade
- G
Return Air
Steel
Combustion Air
Roof Deck
+
Exhaust Fans
O.K. to Wrap
cS "
F.A.U.
Framing
C. e/
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
Finan ZRJ 1,
Final
BLOCKWALL APPROVALS
POOLS _ SPAS
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
cw
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
ao
Appliances
Final
Final 0e, of
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.1,
Smoke Detectors
Temp. Use of Power
Final 1�&.
Q3Utility Notice (Perm) 25
COMMENTS: