9908-125 (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
743025
B 14/30;19!
D e -Signature of Contractor
OWNER -BUILDER DECLARATI/N
I he�eby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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).
I am exempi under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one Pf the following declarations:
( ) I have and will maintain a certificate of conSent't6 self -insure for workers'
compensation, as -provided f6r by Section 3700 of the' Labor'Cocle, -for the
perforrihance of the work fo�which this permit is issued.
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:
Cartier Policy No.
�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 I manner s . o as to become subi . ect to the
workers' compensation laws of Calif ia and 'agree, that if I should become
rovisions ofA9 tion 3700 of the Labo�
subject to the workers' compens 00,rp i PC
Coclerl'Z'�tiill o with comply with tKose-provision
,p -Z . .
DAU Applicant—M/ f-i—
Warning: Failure to secure Workers' Compesation coverage is unlawful and
shall subject an employerto 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 Applicationis hereby mad6 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 above information is
correct. I agree to comply with all PP& and State laws relating to the building
construction, and hereby authorizeyepresentatives of this City to enter upon
si
the above-mentioned property /fc /�ns t o p rposes.
U
4E , c I J r,
SigKa"ture (Owner/Agent) Date
PERMIT#
1
BUILDING PERMIT
215
DATE VALUATION SJ%,5.)7.A TRACT
LOT �7
JOB SITE
ADDRESS 79-453 CKTRINO
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
nt,11LIF 0XIM-p"ri, 1 1.1,
"ClaPIRUS
AS A YkVtlkf Qn% S 9,7 Q
111%��, . 6� 1J,
31-3770 AVAERMLZAS; S714" A
'78-090 CALLEE.4;.MADO 5XF 201
LA QUINTA CA N253
GA QUINTA CA 92153
(760'1771-2567 CMA. 5407
USE OF PERMIT
91NOLE FA NOLY DAVULING
SF-co-i"GITA DICULTNUILOCK WALL
014..Injut. 7wo ReDuk:�rIC)r'l ON PLAN CkWaX., �FWS OR A)MLIVILU
iSMAtANCE 0F.SAMEKAN TYPE,
STOM CO'HISTRUC17014 4,697AW SF
11041CHITIN.1710 892,00113F
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PERMIT r, 9E1.9UK%kRV
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Cat4STKUCT1014 FU 101-00-4184X*
PLAN (111-TrX 9.7,F, 10 1 4W _4139-1; ( 9 $111719
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JNI E C 114, kN I C A L F R E
WXTIUCAI, 10.1 -OW -420-000
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GRADENTG PI I -M W! �000423_000
ART INPUBUCPLACES
'DEVA-0t3tm INPIPACT M
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RECEIPT
DATE
E 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
Exhaust Fans
O.K. to Wrap c4j-
F.A.U.
Framing
Compressor
Insulation WX�
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
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines Q1_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
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)