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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
Protescicoals Code, and my License is in full force and'effect.
License # Lic. Cla;s Exp. Date
556236 C53
-7 - o, - -�, I
Date Signature of Co tractor---n-
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 Policy No.
(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: - ADDlicant
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
& 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 herreby authotiZe representatives f of this City to enter upon
91 �, . . �/ 4 -
the above-mentioned propert nspectiompurposes.
yk'17 -7 7
Signature (Ownpr/Anpnt) Date
PERMIT# if
BUILDING PERMIT
DATE VALUATION $16.-C
.410." LOT TRACT
JOB SITE
ADDRESS 7,11-830 BAYRERRY LANK
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
ISUNRISE PM -LS
'78-830 BAYBERRY LANE
�W28 EUCHMNIR.
LA (1, UJ NTA CA 92253
PALM DESERT-— CA, 92260
(760)340-35,21 (,*BL0 1604
USE OF PERMIT
P001, YANEYORSPA
�PO4QJ, & SPA OWL_)�Al, AXM AMXJR. RARW7411 REQUfM r, OR
PML ANDIORSPA 16,SKOO LS
ESTMLATED COSTOr? M, N-STRUMION
U45MID-1019
PE RMITIF UE STAPNIAW
PILAN CBECK Ff-T,
r, ONSTRUgrIONIFFE
MECT-W411(ZAL FEE POOL 10,1-000.421-00101
E-1 E C VRICAL rFX, -- POOL 101-000-4210-000 S45.(KI
PLUN4B IWO FEE - - POOL 101-000-419-000
ISIsfB-TWAL CONSSTRUMMN AND PLAN CHECX
$393.00
LESS PRE-PAIDPEES
S0_00
'TOTAI, MMIN FR&S DM,'NOW
$393100
RECEIPT"
JDATEF
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplac T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
E)derior Lath
Drywall , Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel _/.2 __� , "A�__ _�__
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I I
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
j
bw-4 64
Gas Test
Appliances
Final
Fifial
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: