9907-373 (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
611171257 i; 212X201
Date , ..1� f% Signature of Contractor
xr
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, asfprovided for by Section 3700 of the Labor Code, for the
perfor ance of the work for which this permit is issued.
(have and will maintain workers' compensation insurance, as required by
7
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:
Carrier1^a� ^ Policy No.
IZL, YAL IN y. C`0.V�, OF
/ P9. I b 5.^I'MS i
(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 shalrforthwith comply with those prows onjs. �1. ' E
Date: Applicant �4
Warning: Failure to secure Wo4- 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 performedaunder 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 for,inspection purposes. a
Signature (Owner/Agent) Date- �f
•BUILDING PERMIT PERMIT#
9907-373
DATE VALUATION Q277,022 ft LOT 16 TRACT 24890,•6
JOB SITE
ADDRESS r 7.0432 LIGA
APN -769-680-010
/
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
81"CulT• T.7r1T TCT1t� 7 1 r/
Al L•i...1.M 441 l#1...f.•til[4 4•..+4..
0 4 rca TT re 7 r,r'NM'T A I' rrlt O4 r ixlr=
�I.1' •a„[rt.,:,/..i i 4• I.IJ[.A ,:i s,li
S ;PARK PPV A STT, 400
s ..PARK .PLAZA, SUlTH 400
l.1:4''ANE CA 9261,4
IRYINEC19261:
t
`)49)251-61W CBILtMyi
USE OF PERMIT
SINGLE RAMILa'rJWRI,UN '
-.LOT 1.15 .i%t•A 2C PrIbbii"i' 00FIS NOT INS:i:MDE tBLOCis. WALL OR
�'U i NIC«'014 �ia�i`+,iaON �.3%S.iiO SF
PORCE.PPAT101 312.00 911,
GARALOWCAlC)~+f.: k+ (+t/S.ttU 3
A.", `�,A 4.16'3'9 A RL.V �v/'!3 , Vn' �e••01i 7..'Y 1 d.'l V �!F. k%lp'YT
27 ,0 2 Z. 0
�p g) {'y�- y .pyo l�y��[ A
TI E
CONSTR70JI0110ril FFE 101-ili3U-418.000
fn,, KN Cl -WC K.. 1.0114*439 'Y18 S?,024.03
t�iL"Cx1A+'dSCAL FEE 101-000 X52.1-000 S .tJt3
EMIC11flUCIM. M 101-000-47, -000
YLUMBTlvU'FHE 1.01-00* 4l9-000 $Ititi.ST�
00- 3r°7 -�%(i� 3r° 710
c1xADMC; 101-000-4.23-000
Or'�iIrLO'PL'R. J:NLP .(",f F M.$5 pi97 elf3
A14T IN PUBLAC l'.C,A.CES - T ESW 701 -OW -255.000 ka42.56
CK
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PRE -PAID ITES
$0-01)
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RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
,`/ �/'
Ducts `
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck*
C,V
Exhaust Fans
O.K to WrapX
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Party Wall Insulation
Fans & Controls
Condensate Lines
Party Wall Firewall.
r
Exterior Lath
Drywall - Int. Lath
C.4 mnge—
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
GV (%'
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
. GU -
Appliances
Final
Final
Utility Notice (Gas) "v -
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) — - Icz
COMMENTS: