0205-045 (SFD)LICENSED CONTRACTOR DECLARATION
thereby 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
53 3 610 B We
t
-"
Date' ��� �� �"� zSignature 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).
( ) 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.
(,) 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
permit is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier - STATE FUND Policy No. 07152
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date? r/^ �l /- -^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
i 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.fordinspection purposes.
Signature (Owner/Agent) / ` r --r Date fti-M
BUILDINGJPERMIT PERMIT#
0204,10*
DATE VALUATION 07.G22,2M LOT 41 TRACT 30125_1
JOB SITE ' + '7�!'43�01114h't ED0 C 1i�a�L
ADDRESS
APN
OWNER
CONTRACTOR/ DESIGNER-/ EN INFER
G>� lloms,
77.564 COVIRDRY CLUD PRWE MIME 137
77.64-3AsCt,?'i1NMs. Y'CLUB D:C ?Ui�''1,? 150
PALM DFISIMT CA 92211
PALM DESERT CA' 92760
(760Y172-8274 274 MU, 11-1
USE OF PERMIT
S00 • 1..U'1'411 4I 3P'L OZ4 2-R 'PI:f1MIT i7ORS, NOT INC.LUDZ L ,LOCK 1�J�-LIA
POOL,. SPA OR. �k�.I�t ENA, 7 APPROACH. "40%. PLA)i CHECK M
PYMtYCTION DO TO iN ULNI1':L B 1YUt3.t1NCE OF SAMIS MAN r0-
COU OM CONS1 RVC T 1011 %42010 sy
PORCHiPATIO 123.00 SY
GAPLOWCARPOU bfS3,011
E SIMIA 0 CISS.0 OF CO1~!'MUCH 14
CONO11leUCTION Me, 101-000-418.000 flly1 hio
PLAN x:41 WX K?1F. 101 -WO -439-3 18 007.31•
YM0HAN10AI- F9 Z 101.000.47.1.000 $109100
WECT11CALIFI 101- i ,20-000
1'T713Y>11BINO FEM 101.000.419.000 $1.0100
STPONO MOTION PZZ,- RIMID 101-GD,0 231.000 $70.78
QRADI O PER 101_-000-423.000 $20,114
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f- 270-000-445-000 l000ry,t4000
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FINAFiCE DEFT.
{
RECEIPT
DATE �L"
BY..
DATE FIN LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
2,
Ducts
_
Slab Grade
Return Air
Steel
2- 3 -
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap_
F.A.U.
Framing
�� _
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
S- _ 3
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_� -
Heater Final
Water Piping
Plumbing Top Out
_
3
Plumbing Final
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)