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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Ziul r }T P ll� iV'rWN
Date °' Signature of Contractor nf' -' �•r",
OWNER -BUILDER DECLARATION r
1 hereby affirm under penalty of perjury tha�
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). a c
() 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 11for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor-,Code�-Jor the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier i � �L", rr 1zl�ct'i:f Policy No. 1703624.03 .
(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: - s, ?Applicant r' .,s ? .
Warning: Failure to secureW tkers' Compensation coverage is unlawful and
shall subject an employer to ciminal 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 hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
O
Signature (Owner/Agent)^''fes''- ^� Date �'F
BUILDING PERMIT- PERM'T�06
497
DATE VALUATION lPIM2A LOT 7/ TRACT2:X22.1
JOB SITE
ADDRESS ^7�/ %i?' ,:o
APNj•,
2
OWNER
CONTRACTOR / DESIGNER / ENGINEER
3 AiIicu des:?Ud t' -4 So
C'e.:lS�RtTit3i►vi'+'.�1.1e''.;)iL�.)'�•1..u' a...as,r'G.
5005 C"iy.1A •Er.rn LA
50'05 E.?'it��A�31r:�����=5�1•�. »�: ' .:31
PAI -AA 1P;R1?'fG;� C.A. 22eA
PALIASVR.NM
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681
USE OF PERMIT �.
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P0014 61at�0q DR1V!,Y±1Y'.#,Y.APPl3.OACH
ICT
t IA COMIRYa C TIOA U45100 V
t� -1100-418,000, V44.5
e3
PLAN C:141t;c,,Ct, ri�1? $6110.73
bA1C1• ANT'al.D..,
�I.If.GiFt:l4 r`s y t<'� 1.Lt1-kl�.`}-rt.��,�^'••(7(1� �1 i'r!`.SiFf
PLUMBING 729 101-000-419-000 $ tOOS
STitOMO AdC'4 1014 FSE -• MID 101-000-241-000 312.93
4}RADia^Ic .1+e 1: 1 tD14( il(��2 S, fDOt�15.�
FEE. sb,405.o0
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NTA
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RECEIPT
DATE
BYDAT
FINAL
IN
CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
,Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills .000
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 APPROVALS
Gas Test
Electric Final
Waste Lines'UP
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out V
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 APPROVAL
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 40
Final
Utility Notice (Perm)
COMMENTS: