9907-386 (SFD)LICENSED CONTRACTOR DECLARATION
`Ijhereby affirm under penalty of perjury that I am licensed under provisions of
6 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
t3Jf.3�6 1t e- Uj�+1-Y20i
Date- Signature of Contractor• , �^ V`Ir� "G�''a'�
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.
(AJ 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.
I IT
ROYAL INS. 0' 1 C45;1211r,
(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 subjectto the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensatio,n provisions of Sectio 00 of the Labor
ly wit
Code, I s I fl hwith comph!;Fh eq ro�vise
s
Date: ;4 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 application 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 Propert yf-r ins ection purpos s.
Signature (Owner/Agent) �• Date l�
PERMIT /t
BUILDING PERMIT
IPM17-
DATE VALUATION LOT TRACT .
5/ 19311,11.24
JOB SITE
APN
ADDRESS 79-156 UGtfi ,
7q�►^t•�►il.ilibh
OWNER
CONTRACTOR / DESIGNER(/ ENGINEER
+
lit�tA vwti-J {.•
411101r +�'� JR
1101✓M to11sif-.0N�lla;:+♦ �1VAl115 ., �I'.1
IRVINV CA 92614
tPV1NIi t'.'A 92614
f9,i�}1xt1-t�l(N't C,t31,# Sfl7.'•
USE OF PERMIT t
NID - i10 I R S''L,AN i1i.-`u4 fi I zh:rt%3 NoL 1wt ►.wt iSF.,t_CKAir UL,
t:)1t t't`rUf„'lS`;o l35..PW (:HIr%iw lit?1)tK r tm APPLI)al KIR ARIl1't'WU
CiSi'•?I�d C3p1,�t�xti*�"Tt��i�t .a,w"71.fk'i :sig
POR01A)AY10 31[001151;
0AXA{ tFai:i4liP(*X 763.09 311
&.TIMA' VI) COST € F C 0M11'Rt3CTSION
312 14, S! ii
1'i;RMIT :FEE Si1MIVf..iiR V
CONST REfQ"t ION t4,.H 10140)-418-W) $1.4 t6.541
rn,AN caiTf•`K,
;r.toNTMIcig.1-0 101: -tit •. "1�'};)'1 xl a,c
Eit,>~CTRICAL OTTF 101-0004.2G.G-ata 12:55.4J
I'Vi WINO111, 8 10i4XYJ-419-{Riff) $221VLS
.
g9't2QNi t4tC)TS{11ri 17P1"; $32.11
. CRADIING M slN)P ,
1'hEVIE"s..t✓PFAFMPACr iX $i;W0.40
ART iN VUHLIC PLAf;,'t 8 - RE14W 70 t -w " *000
r;� V
S4,9I07ml
RECEIPT
DATE
By '
DATE FINALED
INSPECTOR
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
Framing
_ TUU
��
F.A.U.
Compressor
F7. 4—'- c' -V-
Insulation
,
Vents
Fireplace P.L.
Grills
Fans & Controls
Fireplace T.O.
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
O CS40
Final
• BLOCKWALL APPROVALS
Final
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
O.K for Finish Plaster
Sewer Lateral
Sewer Connections
/
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances t
+
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.1.
Smoke Detectors
Temp. Use of Power
Final +
Utility Notice (Perm) - �,