0004-006 (RER)- 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.
VLi ense # Lic. Class Exp. Date
615536 B
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).
( ) 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 acertificate 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
�.Peetion 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 1545701 Policy No. STATE FUND
(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
wolkers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
j Bode, I shall forthwith comply with this pro(9iSions.
ate: .`Applicant�����
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil.fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. -
1. Each person upon whose behalf this application is made & each person at
.whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if_
work is not commenced within 180 days from date of issuance•of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the,building
construction, and hereby authorize representatives of this City to enter upon
(the above-mentioned property foi inspectionpurposes.
/$Ignature (Owner/Agent)✓�'ti'_.. Date
-?fib" BUILDING PERMIT PERMIT "
D TE VALUATION LOT OW4-W6 -. TRACT
$1x00.00 -
JOB SITE
APN,
ADDRESS 46-8551':L[4r:1•LLAM) PALMS
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JACK; LWDERVl100D
SHAT XWCf HM ES ADDPIYOWS
46-655 MGEMAND PALMS
PO IM 3013
.LFA QUiN TA CA 92253
;.ANDERS CA 92285
(160)364-218'i CD1*
USE OF PERMIT
n
FRAME 11' 40 OPEld11JO TN YXISTINO WALL�D1}B WEM KITCHEN/DYN
n
t
a 'VALUATION 11900.00 Le
%
E,sim"a" C06 r OF CONSMIM ON
119W.W
M&EI FEE: S17.fVWARY .. I
PLAN CHS FEE 102-00P-4350-318 $27,95
CO, WSTI:UCTION FEE, 101-000-418-000 $43.00
SROIdf1 MOT1OA FE E - REStO 101.000.241.000 $.50
e
SUB -TOTAL, CC MMUC ION AND PLM CWXX
$71.45
LESS PRE-PAMFEES
$0.00
`!"O'T•AL _N'= T? ES DUE NOW
571.E
fC./
RECEIPT
DATE
olBY f
DATE FINALED
INSPECTOR
Iv
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
F.A.U.
Framing
Insulation
_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—cro
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
Existing Wall Framing
Gable End Truss
6' x 10' HDR 01 or better 11'4' Span
4' x 6' DF Past
Proposed Wall Framing
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
ATF 3 t7d BY
__940
d fr, C E. Ctf y
Drawing:
1
Site Location: 46 855 Highland Palms
La Quinta, CA 92253
New Living Area:
0 Sq. ft.
Parcel #: 617-061-008
New Covered Porches:
0 sq. ft.
Owner: Jackie Underwood
DRAWING SCALE= 1/4" per foot
Drawn By: Phillip G. Brown
760-364-2187
V*q State Contr. Lic. # 615536
Sun-KingHome Additions
Signed-
Date: `�- 3 _ a
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