9808-149 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W Professionals Code, and my License is in full force and effect.
O :3 M License # Lic. Class Exp. Date
ri CY LO
w,<ti}�
n Z r-- /ate _`'� Signature of Contractor—
CD 0
J U CCD
) OWNER -BUILDER DECLARATJON
WLU 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).
( ) .1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M () I am exempt under Section ; B&P.C. for this reason
U0
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION'
It Z 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'
LW compensation, as provided for by Section 3700 of the Labor Code, for the
�. J Q performance of the work for which this permit is issued.
n Q L) ( ) I have and will maintain workers' compensation insurance, as required by
j 0 Q Sexction 3700 of the Labor Code, for the performance of the work for which this
L LOF- permit is issued. My workers' compensation insurance carrier & policy no. are:
_Z Carrier' Policy No.
co 5
r` C) STAT13 I' rNl)
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 Califomia7�nd agree that if I sh000 become
Subject to the w/�rkers' compensation provlsl ns of Section 3700r'of he Labor
bi, bs 11 fo7thwith comply with'those pro , jo • .
ate: �) �4,.t. Applicant
riT—
2
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
k* 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, p sentatives of this City to enter upon:
the above-mentioned property for iispect n pu seS.
!Signature (Owner/Agertta-' f Dat/2i6
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT ��4;) 49 TRACT
6
.S164.96:LSl3 7 b 2
JOB SITE
APN
ADDRESS 48-375 C'A"SITA DRIVE
O�►�/-.tk"8�-Y01��
'OWNER
CONTRACTOR / DESIGNER / ENGINEER
R0, BOX 1716
79-295 KANC1-10 LA QU11,TTA DR.
LA QKJ1 YI'A CA 92' 53
LA QUINTA CA 97253
(7(A))7 7 t - 1941 C'K0 294)6
USE OF PERMIT
SINCI
81+ A - PLAN' k. LOT r til, P3 R M11' 1)JF? NOT INCLUDE ffl eY.X WALL
C.+I:.'POOL. PLA14 C:IIECK FEE REDUC:F..L) 739:; FOR, i14t LTIPLE ISSUAN17 OF,
E.
SAXIC PLAN TYPE.
OU11 ON4 GOjV:,11MU 1 iON 11.975.00 13L.
.
PORCHYYA"TIQ 1 .00 S*'
GARAtAYk !ARPORT 465.063V
. .V''-C�i a i� u r;�ST �� C.���:�rT.t'�C1('.$31s,' °
�l w,!D6� St)
PERMIT FEE Sltifl' M R%
CON T KUC'r10N FEE 191 -OW -418-1)00 a86" i0i)
1'J,AN CrrI;C.K FF1:. lfj1 {}(tfi-d3a-31$ $1-9, 7"
L X-1iANICAL I ii 1 U I -t U-421-UQU a 1 U9..f}tl
6LFCf__ WA, Pali 10i -000 -420 -OW $1:15.93
N1i.1J-NIBINer FTE 1014910-4.1*44X t1 $155.25
`;TJt G N1(YT1f)1+ (.1 F -1 8fi1I� 1t)1 nt t-?dl-(tf () $36,50
ObVy NG FIX 1111-t)a)-d23 t}t3? $;l+.Gist
Irani,)LS f RUCrURff" FT1 111.5-000-44 342
A1t'T EN Ijf..[R1.1C PLAC"1s5 162,41)
a
A1,;4
-AT, C0Nv�S I'RIJC°I'10N AND F9.,AN ("4ECY.
$:S,108.57
AUG 2 �oc� LESS 1>fu:-PAID FEE'S
$0 aU
'f OTAL PERMIT 11PR 4N DOF NOW
555,3+1)83 47
.✓ITY®F LA 6 MI
RECEIPT
DATE
B
DATE FINALED
INSPECTOR
+-
if
USPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILLMG APPROVALS
MECO ANI CAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck - a
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing -
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final Z
Final
BLOC rl 0WALL APPROVALS
POOLLS - S PAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLLUMBONG 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
S r Lateral
Pool Cover
42!4Connection
Encapsulation
Piping
_
Gas Test d GJ
Appliances
Final
Final
Utility Notice (Gas)%_145'
ELECMCA L APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Usse of Power
Final
U014 Notice (Perm) f-
COMMENTS: