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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
7141 k1 i 7/"-11109
9 its
at Si nature of Contr, �,.
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 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.
()6 1 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.
(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 California, and agree that if I should become
subject to the workers' compensation pro%�S!ons of Sectign 3700 of the Labor
Co�de�' I sh I orthw' la-eomply withthot ro'vis',o s�� ..--•- --
Zate/ a 1�Applicant
I
Warning: Failure to secure Workers' Compnsa4lon 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
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 t
construction, and hereby authorize representatives of this City to enter upon '
the above-mentioned prope for insp4c V.n purposes.
USignature (Owner/AG ge Date
PERMIT # CONTROL #
BUILDING PERMIT 9X07-20
DATE VALUATION C:sD11Y4i W ' LOT TRACTVit%' y� f� A
�j
ADDRESS 794135 A.S111AA 1r�J.AE' JOB
APN 604-375-1109
OWNER
CONTRACTOR/DESIGNER/ENGINEER
f1 t;A'�"a7'"f�'�7'rf9)Pl tl"f:T [ ��ldiafi7�TVYtf'C'
1 �.\.1.\ilJ i.l ✓/LTJ' YJ.i \..is l.Jf\1,1/NA'!i.i lrl•kJ
n ?P9YT�?yt'voxwtZ'YI rr%Ik.,1A i'�'kri-m-C
Vt-•iJ 1, A+t\, Y!i.!„•!J \JJl.1dYt.l,�.i.tl.l,i fy✓v!
I D5 SO. "D" S 1'UI ) .912, #200
1535 SO. "T3" -MRCEN, $'T'E. #200
SAN 13ERIvA1t_131NU CA 97.409
SAN CA 42409
(909)Mt 1-6007 CRTA 2120
USE OF PERMIT
STN43U. FAANIIIN DWELLING
Fifa f, PLAN 2A, LOT 81 P,E3MT .DOES NOT INCLUDE }3LOCK WAUS
(AtV00L. PLAN C1 EXX FIS; RWIXF-01131.' 7M49 FOR MUL1`LPLF,1SSUANC E,
tri' fir\.dvill, PLANTYRE.
J"kiNCT C YNSTRU d.1 IN 1,241W SP
f'O:ftGi3/PAiiO 36.00 Sir`
GARACi_i ICARPC)RT 430.00 S—
�i�Y�i•SiAtT anff �!'�i1a�7Y yi! bilJ1��8. iE\QJ i��.3�\.FFtl
�il��w��l•\3V
PERMIT ;a+ RE 5liiiilM.. RV
PLAN CHECA FEE 10.1-000439-31.9 $11.3.89
CtaM'T°RUC rION.RZE 101 -040.415 -OM, $554.00
VMCHAXIC A 17M 101-000-421-000 $47.00
1•::LRC-17RICAL TIM—. 101-000.42.0-000 $ 10.4.68
PLL M1AINQ F.EE 101-000-119-000 $119.00
STRONG M0TfON F03 - 101-000-241-000 $81.04
ORADTNG FEE 101-000-422-000 $211.00
1��t2ASTTii1�;7.'111<Ta;'t�,Is iiS-4(10-413-3�€?. 51.79�.9i.
a
SLf tNI' L�'0N',TrRb&1!QN �1AI> PLANC,;f�ECK
�2,76f+.5G
d 1 J ! LESS .EREE-PAID FEES
$0.00
SEP 2 €3 i6;,,,
.
£ii'1A1,,P r��€i11 IT VERS DUENOW
ECEIPT
DATE
BY /
DTE NALE
Vie
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ /_ _
� / �-�
IIS
Underground Ducts
Ducts
Slab Grade
��p
Return Air
Steel
Combustion Air
Roof Deck
_
. ((o —Q
Exhaust Fans
O.K. to Wrap
j a?t -rt
F.A.U.
Framing
/- &F ,�-
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
Final
%
POOLS - SPAS
BLOCKWALL APPROV LS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
/g /fid
Heater Final
Water Piping
��
( ! /
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
`o �o - �!
Encapsulation
Gas Piping
Gas Test
Q
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
t
t
Final
Utility Notice (Perm)�j-