9907-378 (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 nr
16/ate F 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).
( ) 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.
Y" 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' compensatiori insurance carrier & policy no. are:
Carrier Policy No. q
(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
sub -eft to the workers' compensation provisions of Secti n 700 of the Labor
de; I shal fo . hwith comply with.thf s rdisl
ate: t Applicant / .�o
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000; iri
addition to the cost of -compensation, damages as provided for iri Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject" to the. conditions- and restrictions set. forth, on .his -
application.
1. Each person upon whose behalf this application is made & each. person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & "shall, indemnify
& hold harmless the City "of La Quinta, its officers, agents, and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of., issuance of ' such
permit, or cessation of work for. 180 -days will subject permit to cancellation'.
I certify that' I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives f this City to enter upon
thea o`ve-mentioned property, - r ins ctio pur eg. `
r
'Signature (Owner/Agent) Date l`?
BUILDING PERMIT PERMIT#
4i4itt7-3'3
DATE
VALUATION LOT. LOT i TRACTJOB
SITE
ADDRESS �s7tn��,
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
' I-I'S1"R'.'r131.1U.".1'"P'" � TiC
ti,✓ 1. ..•/,,'�41 r) lP �..r
r`'�`''°,""'t�rt4 r'l:'' 131111,rT*nf �r'itrtiY' l'mc
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i H'AK Pjr1Lf'f!s- a"Jn twf
J 1 K PLAM, Se. N'i`s 400
JARVINE CA 926141
IkV). l;, Chi 910441
USE OF PERMIT
5NCaLE VAA'.1LV I`:rWELLIN
51-70 ^ 1.1DT 4S .MM 2410 G l PM T L'9t::i» 140T I11iCITD UQCK ,VA LL
Y 0 X IN4.R d'llTv.ti
16".w sf
�s:rKE�`t-�1�14,S,Si'Y 591..11 1�
,)N fqlr XON
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305,222.60
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CON:YN.6,IC:I.K N FUR 101$ 00^'$MR1Cif) 5ii, fihfl.5f1
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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 Gt/
Return Air
Steel
Combustion Air
Roof Deck �GtS _
Exhaust Fans
O.K. to Wrap L --r Gv
Framing �� _ �1 ,�
F.A.U.
Compressor
—11
_
Insulation _ w • 7—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall 1 '
Exterior Lath
Drywall - Int. Lath
Final'
Final — W
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
•Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines (,G
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
c
Final
Utility Notice (Perm)