9911-071 (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
. "rofesslonals Code, and my License is in full force and effect.
IF 'License # Lic. Class Exp. Date
Date/ r-;� `� Signature of Contractor''r
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.
( ) 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 A policy no. are:
Carrier Policy No.
SE All M) ND 0 44461-0004.92, 1
(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'provlsions.
Date: i 1 ! 7 ' Applicant—
Warning:
pplicant 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 tq
any permit issued as a result of this applicaton agrees to, &. shall, indemnify
A 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 foPinspection purposes.
! a
Signature (Owner/Agent)` % 'el" ^•+L " Date 1• F%' �l
BUILDING PERMIT PERMIT/i +
DATE »3 � VALUATION -� LOT `qda TRACT 'x421)
ADDRESS 74-0Q) UJC, IJt;RJN� I' I.,
APN /@/9-5iG.023
OWNER
CONTRACTOR / DESIGNER / ENGINEER
112t?: I ; "f'.r+?;. I ,i-A3NMI:i) 00": r., IN, C.
pw'r' ?31S :x. ;1,t.l_11 A :"rr. � C:JVFi,111(..
7+1-W,HWi'1ii. MIL.103
74785 HWYiiiy11105
INDIAN WELLS CA 92DO
INDIAN -WFLLS €.A 92.210
CM4 _Vc 14j
USE OF PERMIT
.�1NGLE FAh'II'l Y DWELLING `•
SF • PolAfff D0133 140T INCLUDE 11031., OR BLOCK WALLS
M CON .191r.iZ'{.!1t JA`! 3.0I J.00 . fr'
PORCH AMO 20.00 S1.
1LJA1kA 3WUAi4P()R',V 759.00 SY
c;0NJ1k1JC 1 T. UN ME, I Of-11)VO-418-M) ��tL� a(►
P1, ANc'`Jfi4', ' FEF, 1 2-flt?{)_r1 tJ- 3 SIR2tt.C�R
MECHANICAL FEC, it�i-(its �1�1 �Otl fi1.�7.(+a►
� € 1itlCAJ„Nits tf31 (f(?�J-d�fi-(31KT 3221.7=J
"ITZ01KC, MO T Xr;M .Flit: - W& SID 11t 1 - M -241, ti0 xl3 i�
GJ.tAWN0 HT, till -Q o(!- � i•t^irfl 3 ia,t�tJ
1A-VYA,()VXt IMPACT FHL 11.90,1.00
ART M PfJW, (C P1.AC3 ;; . RTS,,W, 701-000-7.55-000
RM-1i".i'1'AT, COMM UCTIONV? NT) ?1,ANi t:i'11:C, K
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G . 'LESS"1'#T E-PATI1' 1-135
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RECEIPT
DATE
BY
DA F E
INSPECTOR
ill
INSPECTION RECORD
OMRATION
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 Z Od
Exhaust Fans
O.K. to Wrap —Zp —ctiv f2
F.A.U.
Framing J—/0-0-6
Compressor
OF
Insulation�lo-015
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath •-� .—�
Drywall - Int. Latham
Final
Finalif/tJ
POOvLS - SPAS
BLOCKWALL APPROVAL9
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
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 /
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final _
Utility Notice (Gas) CV/
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 —&V
Utility Notice (Perm)
i
4
P O BOX 1504
Building 7yd /,� r% t
Address // LXJ Qi,,,
Owner /]/I
78-495 CALLE TAMPICO
1 0,ry fl'17it. LA QUINTA, CALIFORNIA 92253
(�A ti 7 keel C 17, JA)
Mailing
Address //�/ S dcd 7P /l/
Citv��� Zip 7 Tel. r�
IM113 ?L 7fb 11,' 1/1/50
11 v, .rPt r,r
Zip
State Lic. / -City
& Classif. /- d �''J'� Lic. # �s; ;
Arch., Engr., �`
Designer ,�
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. ' 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or thathe is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by -any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
l: 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I II'
as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
i 1 1 am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT., If, atter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE'CONNST. / OCC. GRP.
A.P. Number W
Legal Description 4 7
Project Description
D 1,N it
U
Sq. Ft. 30'73 No. '11 `'�No. Dw.
Size Stories Units
New ❑ Add ❑ -Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
A
Plan Chk. Dep. �5t�
Plan Chk. Bal
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc. d
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION