0001-247 (SATT)LICENSED CONTRACTOR DECLARATION
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 co Professionals Code, and my License is in full force and effect.
License # Lic: Class P. Date
tiW to u7-107.1 B •� 07131i2ai
� CC
cZ r- Qate `^ %�'� Signature of Contractor.- -
co 0 OWNER -BUILDER DECLARATION
LU W n I hereby affirm under penalty of perjurythat 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).
C1 O I am exempt under Section - , B&P.C. for this reason
LO
N Date Signature of Owner
Ocli,
d Q WORKER'S COMPENSATION DECLARATION
C Q I hereby affirm under penalty of perjury one of the following declarations:
In H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided. for by Section 3700 of the Labor Code; for the
O J Q performance of the work for which this permit is issued.
m Q 1;) (r I have and will maintain workers' compensation insurance; as required by
Q 0 Q S ion 3700 of the Labor Code, for the performance of the work for which this
11' U')!- permit is .issued. My workers' compensation insurance carrier & policy .no. are:
Z Carrier Policy No.
OBD v of r._,L'...•11t.3 IiIG-t.IV, (7%_•✓el
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 California, nd apree�t if I should become
3 subject to the orkers' compensation provi 1 hof Section 3700 of the Labor
C e, I shall fp thwith comply with those' visions: �f at
v 'L 0J Applicant
• Warning: Failure to secure Workers' Compensation coverage is unlawf I 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 rand Safety
for a permit subject to the conditions and restrictions set forth on his
q* 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 dayswillsubject 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 herebyfauth-Uhzerepresentatives of this City to enter upon
the above-mentioned property for Inspect' purp
Signature (Owner/ gent) Date
BUILDING PERMIT PERMI4¢
DATE VALUATION SA64,961.50 LOT T1 TRACT ;>7Y,3
JOB ADDRESS X19-370 Y�,� FAB 'Ii. UN a
APN 649-3864"
OWNER
CONTRACTOR / DESIGNER / ENGINEER
•,• f'1 f!«l�i r, �t]R' QI: AS��T•
1..•f....i&.11 l 1, t Itf I.rl
C,SfVA l`'s• CONS".' "I'll\N
,,,!! t 4...= 1' t f\.LJ t,, I, l
{'6 6 O 1 / 1
79-295 ){Arll,,!'1.O LA 1,11_IIlJTA DR..
i., A.l„itjINITA. CA 94`25i
L,A(.1011!I-A CA �021>3
1-11Y n096
USE OF PERMIT
sit-iJ i.f.li iii 1'E .,%N r 4V-:f6.U.I' iKA., 'N0► JNC.:e.UO f;LOCK OR
I't_ftti: , /ti`;o PLAN NRJi: WI,E ISSUANG11, 1 a3
<iAlb);f F, LAN't'YPE
�.:..,•1 E.m
i'&F(t.:t%11'H i i(D 60.011 SF
[.''e l.lIS (11 COINi tii tt zjMI.ONT ,
Pf!"lii"if FEE .Susi Vl iARY
i
<•'! X'A'.RILIC TION FEE it) 1-I.f()()-414-000
PI_. AF{,{ ('1:17T -.`('.ti. FT-,!' !1 (j 1 -[(�?(tlj(�1.1��i-'(�� I R !s i'74 74
, -
LiLC� "Al""'/`. AL H'lam 101-000 Ail 000 O11)i.01,
E E:1.'"l'Wt: Q. F tiL f ijl-titiU- d1G tiihi S t 1.9:�
PL UMNl fd(i FEE '2S
A:te'�!'i r>N F'F'i: _ t; t:?,�{!ii if/ill-/(�!((�!ff�i-?�11••((�H/�H.1I qtr..
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f�.^r�t•rtvr n5��
I�i:Vi.sl.ui/it 1i4y12i�'l:i' firs �"t,7+.:+.?k1
ikk)` tN N081.tC PLA(.,'88 - R,1 -33W 7()1•UU7-255 U1i tti�.•1+i
til !13 i'C)Tq?,!'ItihlCl"T?s !t "�at-11v AND PIAN 01,WC:K
V3.'?W R2
e Lr,.c nr�: ttu)1-ES,
mn�
'B 01'Al, {'0!:RN11T 1, UFS tD114t, t?i4)W
$3,210.32
RECEIPT
DATE
jW1 �^T,
DATE FINALED
INSPECTOR
INSPECTi SFJ RECQI�n
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLDING
APPROVALS
MECHAN9 CAL APPROVALS
Set Backs
o d
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
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
--
Drywall - Int. Lath
Cf
Final -
Final
BLOCKWALL APPROVALS
ISO®LS a .SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
2. Cli
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Lateral
Pool Cover
S Connection
Encapsulation
Piping
"
Gas Testn
gyp' O
5 Ave
Appliances
Final
Final 41 o e2 c
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 U
Utility Notice (Perm)
COMMENTS: