9911-212 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Datep& 3w
ol
ate ��'�2 Signature of Contractor
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.
( rl 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� fS. L0,M)1QN-V Off' �, Policy No. 'J,f:��i'00419001. i .
,(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 no 'employ any person in any manner so as to become subject to the
worke compensation laws of California, and agree that if I should become
sub' ct to the workers' compensation provisions of Section 3700 of the'Labor
C e, I shall forthwith comply with those pry���.
ate: �7T �Applicant�.
Warning:. Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for .a permit subject to the conditions and restrictions set forth on his
application.
1•. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under. or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold" harmless the City of La Quinta,'its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within •180 days from date of issuance of Such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the -above information is
correct.,I agree to comply with all. City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for i 'pecti a,; urposes.
r1" ignature (Owner/Agent) Date Z)'' 2�` ;
BUILDING PERMIT PERMIT#
DATE VALUATION S16.1%,(44.5q LOT ;S 1 TRACT
JOB SITE�1,� > II.B!iC16.�,NR .�U D
APN
ADDRESS &(V1:
OWNER
CONTRACTOR / DESIGNER /ENGINEER
ktONI 4Av
INC. .
PO :'x.3O3s 810
1425 E. MA.T. RSf'n11 DEU VE
LA, (fit. N'FA CA 92253
F'lff(1lsP 1,% AG 85 034
t
tcef32};57-3{5C C1111A 49190
USE OF PERMIT
LOT 41,.PLAN N 4R. SFO- Kniff DOE-,-, -NOT 114CLUDEMOCK 43 MLLS i.k .
f"001— PLAN Qll !'.A_% i L .9 ft1,',.0 CFt) VV A FOR f4 V '1'i:€ iX ISSUANCE OF
;AME Pi.AX'I k°E.
77.4k S17
C; a ARA0frl';;.AkP4; .W1' 48_1.tf0 Sal"
PERMIT F E, E SUMMARV
CC:+N;i'.I'3ZU(.7114,N FHE 237t-tY.)CAIK-000 :off;0.50
Pf.ANClf1FC`VI T"RE, 101•(1004.39-11$ t17770
fi Cf IAY+?'tCAL r"SIT: t 3`f •000-4^ 1_000 W,0
d'��l.lc`t'�;"l+�;r1t, fieri 1f-1%•il(,~ii••�id(�-t�f"1 :�t3�;.F,(i
lyLi3A ftJi} f f f, I I-{3bsff-��I:3 43di(1 $157,W)
lkittA�'fY'3C)j�!'ril�dl••�rd*ty��'f�113{f�� $1 F, • Sff
IT'!FtAk'"c.t•!C"i
��A�:A•M�b1+O f."#st3 ilii^0(. -4423"000 g r
1:�1i"fZi4 'l'1a1t: Il6'a "V03a�r�-�iii�0,.��1:4,342
ART114 PUBLIC IILA.i.`EIS - lEtfssfl, 701- t-2M-fitk0.
ti4,fji..• i �.�,�y�a7. C.C9t`1�,"I"�1.1C"I'�fahi.A.�1ti11`� l��h��f C:.'t�F:�lh',
; ` i :�:l;Sfi � �1
LES`, P:E E -PAM Ff: m
,; 0 $0.00
RECEIPT
DATE
BYD
T FI LSD
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
,DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
G
Underground Ducts
Forms & Footings
_
`jQ
Ducts
Slab Grade
.G _
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
/
O.K. to Wrap
F.A.U.
Framing
�J
Compressor
Insulation
_
GAJ
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
`
Exterior Lath
Drywall - Int. Lath
- rU
Final
Final
Q ��
POOLS - SPAS
BLOCKWALL APPROVALS
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
��1�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility
S�
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
Final
, p - S'
Utility Notice (Perm)