0312-022 (SFD)LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3•of the Business and
WProfessionals Code, and my License is in full force and -effect.
O :5 ch License # Lic. Class Exp. Date
LU
763187 B 105
r,
Z F,- Date r - ��• �� �� Signature of Contractor • •
CD
O
r` C:) OWNER -BUILDER DECLARATION
J V CID
HLU 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). < .
( ); f1, as owner.of the property, am exclusively'contracting with licensed
contractors to, construct the project (Sec. 7044, Business & Professionals
Code).
ce)() I am exempt under Section B&P.C. for this reason
O N Date Signature of Owner
rn
a Z WORKER'S COMPENSATION DECLARATION
o 2 Z I hereby affirm under penalty of perjury one of the -following declarations:
Lo <p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Lam= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () ( ) 1 have and will maintain workers' compensation insurance, as required by
DU Q Section 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier uT`t`•
coo5 Policy No. 16dG6:E-P3>
Q
J (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.r
Date: Applicant %l ,-� r%
s 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 & e c(h erson a/
whose request and for whose benefit work is performed under1131 rsuant to
any permit issued as a result of this applicaton agrees to, & s 1, ' dei'fv(
& hold harmless the City of La Quinta, its officers, agents an �elploy�k3�,
2. Any permit issued as a result of this application becomes n ill d void if
work is not commenced within 180 days from date of issu inceofCsyucyl
+ permit, or cessation of work for 180 days will subject permit tc cancellat4on,-,
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
or inspection purposes.
Signature (Owner/Agent) 7�' -•� r 2's s Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 4011.-022 TRACT
JOB SITE '
APN
,
ADDRESS S� g �akhlaTLu Y
7'7..x- s' W9
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�t;l .. f sllfiv"t i0, '
�t)�I:a±Ai't T I sol. . c�;�:N�,",+vtY�1flu-� �,1'ir a
200 B, WAMIMIXON ANT- is$7. 100
200 I?.WAM3.i3'C`s'.TON AV #100
E -SCO e1'. MO CA 92025
:1aSLC}.ADIDO Cry,. 9202'x"
(Y60)839-8238 C'1'UI 5413
USE OF PERMIT
Big( Ali L'.''
sm.) - for �, PLAN I.A. 'PLERMIT DOES NOT INCLUDE BIZCK-WAV,131
'POOL, BPA Oft DtRNMAY —40P t�.�ACYL A'%, R KIC-'" ON TO P 014WX
FEE DUE 310. IAULTIPLI. ISSiJAWCR OP SAM'K PL A11 `:"t IyL
CUSTOM C�3r�STF�tICrMN ZQss,�o 911
PORCHPATIO 333.00',
4}pi.11M'rZIf;AisPORT 6N.04%1?
•e q �+�* s�
C� +'�yam��,y COST
'REM . 0.1 UID ,C�LlS A.13, 'C�4J.FT��a9'��.?�UMON
250, t''s6 .40
CO"I TRUC'i ION IIER 101-000.418.000 S1,16"t, 00
I'W4 CI.9IMAZ FEE 101-000-439-318 V41.0I
MECHANICAL FEE 101-000-421w000 $143.50
ELIT, T IU CA L. F12, 101.0010-4.20-000 $102.9S
1'LUMOTAG RIF 101-000.419.000 $1'1 M
STRONO MISTIOW FEE • RESID 10 ) -000-241-000 $35.05
011RADING F19F 101-000-4.23-000 $0.60
DEV71,0PER tIa11'A T lr?,i!$2,405.00
AM- IN 11U'6 LW' P1WMX,0 - :itENIL 2.' O.000a445.000 $136.16
. e 3:£1-T'o-ovL COk7 tu molq AL.1arr:5+r�nyPIAT. am"CTC
3
1$0.00
9 20
RECEIPT "
`DATE
BY
DATJJED
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
d
Exhaust Fans
O.K. to Wrap
_ 7
F.A.U.
Framing
y ��
Compressor
Insulation
o
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall.- Int. Lath
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
Gas Piping
PLUMBING APPROVAL
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
Gas Test
/
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole _
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service 7-1 Aw
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
'COMMENTS: