9808-151 (SATT)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/pate-
1DateqE-2v�//_ Signature of Contractor
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).
( ) 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 oner 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
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 F1JNDI3, 1095
(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 Califorrn ,and agree that i uld become
subjact•to he workers' compensation prqisions oLswtiPK3700 If the Labor
Code, Ishall forthwith comply withithose p ovisiofis.
ate'' 'f6k Applicant i "� J.
Warning: Failure to secure Workers'C mo pensati n coverage is unlawful d
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, 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 abovenformation is,
correct. I agree to comply with all City, and State laws relating to the building's
construction, and herefiy au'tftor�ize repre"'ves of this City to en er upon
the4bove-mentioned property foe ectlon pu oses.
;Signature (Owner/Agent) Date
BUILDING PERMIT PERMI alii�t-��8 CO
DATE VALUATION LOT TRACT
. �(1
-7.528
-�u_ C4' -
JOB SI �
APN
ADDRESS �. jro l ASI 1 A DRIVE
-OWNER
CONTRACTOR / DESIGNER / ENGINEER
� FUEL; 11_,MI:NT
S�'ARK:Sf:(��J�:i'ft.�SC'�'4i.?;d
P.G. BOX I7!6
t!)-2� S I�.1Nt�:! ICi �.t! t�i;IN ['tk T'iK.
LA.QUI.NTA CA _02'253
(M,A)IN'17A C�A 92`253
f7f�(1?T.rJ••)�,fsl (';i1L.# ^�3�Ttf
USE OF PERMIT
SCN101 A NIfI X ATT i 10',17
SFA - PLAN A. LOT* al, AEi't1 a r was No- FN LURE BLOCK WALI,
OR, POOL..trLAN Cr UCV.. h ER RED -1 fCEI) 7.Sto FOR. MUi: 1PI,k ISSUANCE 01
SAME PLAN TYPE
CU3Ti:i141 CON. rRUC 1'1G1d 1,975.0 SI
YC)RCWPA:rI,i 1.50.00 SE'
t;}ARF\C iC�A1tF'Glt'T 465.00 S:'
ESTti��#TED COS OFCONSTRUCT [ON
14.4.9X;1.$0
/,:`GN 'rR,U(;.f10NF'ti:L"• 101-000-41"00 5867.0)
Ta;lll�± MT13CK, FRS- 103--000-439-318 A179.74
N1r-(.11' ''4CAL 111 101'0W_111I-000 $105.00
ELEC1RICAL F�''<E i0.i-000-4204)00 a:?5.i► :
PL NfRING FFY. 101-(1(0-4!9_0013 ?�I5S.2-5
STRONCt M .)TION FEE - RES1ID 101 -000 -?=11-000 $16,.'10
C 401-000»423-000 52(4.00
[1�Itl itA`3'I t U��'I`URE I Ed 225-000-4:93-;(42 4;}.646.75
r:
AK'I' IN VILIBI,IC: WILAICES - RESIC 701-000-255-0iK)
CON IND 1 LA.N ('PIING:
`t~.5,10 ,7
PAPAD'IyYMI,
LESS PRE -RAID FEES
MAIO
AUG 2: 8,4993 7 (YfA.I•, It'F�9a1 111:' �� t'h:NS IYUE N(riV
SRECEIPT
DATE
Y
DATE FINALED
INSPECTOR
NTROL #
I SPE�TIOO �J RECOO ��
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDING APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings 16 .Z
Ducts
Slab GradeReturn
Air
Steel
Combustion Air
Roof Deck - Q.-gy
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing ZC
Compressor
Insulation -XMoK
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath (,L�
Drywall - Int. Lath _
Final U -
Final o1A44
BLOC:KWALL APPROVALS
POOLS - 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
PLQ.DMBNG 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 p - -
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
:-
Final
Final _ G
Utility Notice (Gas) RO�
ELECTMAL 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
i
Fiona j
Uthdy Notice (Perm) - Q
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