9908-122 (SFD)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
'WV25 B IV
Signature of Contractor
OWNER -BUILDER DECLAAAT16
I hereby affirm under penalty of perjury that I am exempt from the Contfa6tor'.s
License Law for the following reasom.
(: ) 1, as -owner -of the property, or my employees with wages at -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).
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
Section 3700 of the Labor Code, for the performance of the work for which this
4 is issued. My workers' compensation insurance carrier & policy no. are:
perml
Carrier PolicV No.
0 U1,11M
A 14 G 1 11 "1
44 '"i -9151
(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 n o as to become subject to the
,,,)anner s
workers' compensation laws of CalifefAia and a ' gple that if -I should become
subject to the workers' compensati?/7 f Section 3700 of the Labor
,p provisions o
Code,, [Shall forthwith comply witDdfipse, provisip
D'ate: 4�, e 0 . , ZZ7 a 22'
/ . 6f , 0, / �
Warning: Failure to Sec ure 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, damaged 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
applicati * on.
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 authorizejrepresentatives, of this City to enter upon
the above-mentioned property for Vi6npeb-tion purpQS
Date;
Sigrature (Owner/Agent)
PERMIT #
BUILDING PERMIT
DATE VALUATION S.194.547.50 LOT IR T�ACT
JOB SITE
ADDRESS
AIN
OWNER
CONTRACTOR DESIGNER ENGINEER
CMIW115
1vtAIRVIN! HOMES
79 -WI -0 CALLE. E9fA..D0,M 201
LA QUffil-VA C.A. 02253
LA QUINTA CA 022531
('160)Wt-2567 CBLN 5407
USE OF PERMIT
�,Nd"_b
SSF-D- LOT 18, PLAN -Z�M,,,PERMIT DOTIS NOT YNCL(fDF,9L,)CK1WAJA;
OR F<*L, 75%.fW)U(_710N ON SAN18 PLAN CKECK k1w, OF, wur-ime,
ISSVItANCE OF SANqW, PLAN 7111K.
PORCHA?A71-10 892.00 4F
UARAIJOCAR WORT 8.%,4A SF,
lip
OF
& _.,fu
PERMIT r, EENLIAMWARY
T
CON�rIRUCr!.GN kTA_,', 101-0W-419-000
PT,A,N POT I.R
iv=t 1ANi1C tq i AVEL
UX Cf RICAL 11FQ, -,4M)-42&,Of)O
PLUIVIBIN,C) f1W, 101-000-419-W)
IRTRONO WYVTON- FEE, RM,,'YP 101401-124 k4." $34,45
GIZADR,ZG V M77 11011 nwx)
A W.0 IN PUILIC PLACES - RESIC' 7014W-255.000 117316. 14
DEVEL(VrA IMPAk-,r IFEF S 1,907.00
MJ1.1-TYY1*AL- (71)N$QRV�110NANK) PLAN CMN -19
V PRE %I
vd,�; .411 MfEES
T(YCAI, VE'RA111' FEC.54 DUE 'Now
28.4.5
RECEIPT
I
DATE
I
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE I
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
OX to Wrap
V
F.A.U.
Framing
iE 11 (
Compressor
Insulation
cn)
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground PIbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
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
Utility Notice (Perm)