9908-127 (SFD)47 LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professibnals Code, and my License is in full force and effect.
O =) M License
y# 7f Lic. Class Exp. Date gt
oZ r-- vQ t/}Signature of Contractor
ZD O
J U C OWNER -BUILDER DECLARATION
Hw r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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). r
I am exempt under Section B&P.C. for this reason
O N Date Signature of Owner ;
rn
d Q WORKER'S COMPENSATION DECLARATION
C) •Z I hereby affirm under penalty of perjury one of the following declarations:
Lo r 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
Oro J Q performance of the work for which this permit -is issued.
Q. U (;#)' I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d LO I— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
ob Z) 3TATE FUND 144 1) t25-99
J (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 Califor2ia, and agree that if I should become
lb subject to the workers' compensati4 pr "vision§Yof Section 3700 of the Labor
1 Code,,l'�{hall forthwith comply with gigs prov>sions`.
Q� ` ,�f Applicant % l
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
application.
1. Each person upon whose behalf this application is made & each person at
.w 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
11
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 al City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property f r nspecfion purposes.
dig"nature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
fs.x,
DATE St VALUATION yt� LOT t�� TRACT
JOB SITE ADDRESS P9-42.0. CE RM)
APN
l F -I W-0299
OWNER
CONTRACTOR,/ DESIGNER / ENGINEER
t-ri [ t1Q 1)e:1 rEC. �. PA!I7E i+A i..L�.}
vit^. wt�°iLY ai0% �i':•3
51-3-7 0 .t1Ar B;sR.f JUDA.% ME 1
78-080 i.'AS,LE ES ADO STT
.
201
LA. QUINTA. G.A. 92253
LA QUINN,
CA
92253
f 7C01'i71.25f J
C;glUl
5407
USE OF PERMIT
S00- LOT 29, PLAi4 3GMR, - P1<btl4fri'a i e023NOT INCLUDMILOCK
WALL OR KJOL. 75910 REVUC,110N ON ,KAN CR l' K FH9 OR t1911LIPLE
fa:1dJ.RANCE OF StAi 3U PLtV1V 3'YPE.
C (STt/W C'ON: ' lt.0 NON 4, 3 ; 5 .. x; W9°l�i�tG�4�PA
TIO 146.00 ISF
0AR-A-0 fr',AROL'7Ld P 903.0 8F
I)CONW Or COMM T1
ENT HAUTE UC ON
1pE.RMIT :R ►UNIM. ftv
ti..•
.
CONSIQ-3T,.£t _1710N da'.EE 101-000-41t"(9i
fJf. t"Fi9 e;l. pp- 101-f,{RE-:1"1q.-1Ik, $;ate,°I.5
-,
�fEC'.k1,13��1.�'l'i3 !?f"w It) i' 'v`• i U()Ss' ;{ ir13,5iJ
;
J T1 •�
('-Ela 19
111.U1 BI Nit; 111F, ) 03 -0(9),-4 19-M.) -M.) $2.21.75
C
:4'1'tji)Nr A?I1f 3f.1zw" # j� . �tg~iSf`R 9f11.t)11d1-241-f)(1(; $7;•70
GI2.aA0�l'3C_7 u`'f (i utl1••(0KII-f2.'1,1;(N)$NX,(to
AWC IN f'1.iS S ; friii.A(>_' 3 - RESI 141440 -25a -d1 )
Dra"b`�c..C.+i'f<t? 1�fifarAF.''T 3^f�4s �,i,yct7.(+4J
30111MY17AI, 0Q:)N,`-i"iVU010N AND MAN CHECK
�;grl�r�.oti
LESS 1'RU—.-ANID FE -12S
Wr OU
TWAL PERMIT 1+'1 if.9 MIC NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS .
Set Backs
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck �G
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing y1.�[.lL
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
Final Q lig
Final: —
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING 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
Pool Cover
Sewer Connection r
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) 6 2-< CAJ