9810-027 (SFD)LICENSED CONTRACTOR DECLARATION
Fa" 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
�J W . Professionals Code, and my License is in full force and effect.
^� .M License # Lic. Class Exp. Date
Zo ZO r- IDater Signature of Contractor,
7 It
_J U (D OWNER -BUILDER DECLARATION
UJ LLJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ (' ) 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). -
M() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
Q)
Q WORKER'S COMPENSATION DECLARATION
o Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
Oro � Q performance of the work for which this permit is issued.
Q C) (}() I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
� Z Carrier Policy No.
cb n s WU FUND 74"r 1.171
r` O -
(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 CalifoAnia, and agree that if I should become
syN ct°to the workers' compensation provisions of Secti `n 3700�of the Labor
k 3 ode, I shall o I comply with thI a provision
Date: Applicant / r
1 f'
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
dao, & 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 propertfor inspection urp es.
Signature (Owngate Al/w/"
PERMIT # CONTROL #
BUILDING PERMIT
.�.ss_timlxr
DATE VALUATION $120.647,01 LOT H/ TRACT
/r/0 -?9 ?�� V
JOB SITE
ADDRESS 'a"s.pkQS,y 'R y..#Fi!
APN-1R0-0l
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1{*;11t~':,'ttHrJ'l1(73]:E'S CORP.
INTIIC10f)�3�rq?'��il!tIS 1,111,01X)p
iL' .4 %V•. 1'1:F�JLv YY- ,l'i V5` ��V
W. iA;R4J'YY HWT
.1282 YY ,El
ITPLAND CA 91785
UPLAND F:.'A 91795
USE OFipPP,E{xRMIYIT��nn
r�± y 1 , ��_ rr py ?��`(
iR`��..AE21: W-MLY 1, rEIL.7.ING
.
SFD - .L iT 'i.3, PLAN 4CR - x-1,7f_tis Ali' Dt'ir"S NOT WCi.Ub.L' BL0'Z WALL SS �1 �
T,R %-;T CONS IMIC'.T:ION' Z003.0E0 l
1001101/I'NF. O 14.00 3
0,AKA.0FJCA.HP0XT M3.00 SF
Ct N$1RvC3'1G N.FE? 101-000•-418.000 S713,00
PLAN C:FT-CX}"!3V, M-000-439-318 $147.79
MCi 1. XIC t' L RM 101-000-42: -000 $47,00
UILEC."DRU< A,, .174 #.f:l-circ-�fl 0-tltit3 #.�t).94
PLUTWI[NC 3:Fi 101 -OW -419 -OW 5L48.Gf1
STRO NO WYFfONFEE - RUTF� +()?4XN� �!-Otit1 $12.06
C: I ADINO Ftp: 101-000-473-000 $2f�.tttt
NF'I', :idw*dt6Ci-443-342 S2,7i0 Zn
AitT IiV I3E3fTC J'd,A.t:f 3 � R:tiSll� 701 -OW -M-000
SLID -TOTAL CON."TMUMaN JhYD PLAN CHECK
x3„9:10.29
LESS 7IR&PMD FEES
WWI
TOTAL PERINIVC FEES DO E NOW
53,9801.9
S �
,
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
, /
`7
Underground Ducts
Ducts
Forms 8 Footings
Slab Grade
/Z ,�� jl ��
Return Air
Steel
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
Elff__
F
Drywall - Int. Lath
4/_/
Final
Final
POOLS - SPAS
BLOCKWALL APPROV S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
Gas T
PLUMBING
APPROVALS
Final
Electric
Waste Lines
_ _ �1_
`�
Heater Final
Water Piping
�+'�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster a
Sewer Lateral
Pool 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
f
I
Final
�j79
Utility Notice (Perm)