9911-211 (SFD)LICENSED CONTRACTOR DECLARATION
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
04 W Professionals Code, and my License is in full force and effect.
O =) ch License# Lic. Class Exp. Date„+y,f t�
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I`
oZ r ate Signature of Contractor
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rU C) OWNER -BUILDER DECLARATION
W LLIrO_ 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
CO 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).
( ) I, as,owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, `Business & Professionals
Code).
co () I am exempt under Section B&P.C. for this reason
nl Date Signature of Owner
ON
0)
iQ WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
LO H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w compensation, as provided for by Section 3700 of the Labor Code, for the
Qperformance of the work for which this permit is issued.
Q 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
a LO H permit is issued. My workers' compensation insurance_ carrier & policy no. are:
f' Co z Carrier INS. WANTI A`+)Y OF Policy No. �1'CIi7.el,'lfel'3�tt.
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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 dgot employ any person in any manner so as to become subject to the
worl�efs' compensation laws of California, and agree that if I should become
X
i:ct to the workers' compensation provisions of Section 3700 of the Labor
i ,ode, I shalVbrtl yat�comply with those prov sions.
Date: lw" . y Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions 'and restrictions set . forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct: I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
t above-mentioned property for inspection pines.
'Signature (Owner/Agent) /./ Date/fir«!-�h��
BUILDING PERMIT PERMITq
DATEVALUATION+�•LOT TRACT�'�
Z 1,7
JOB SITE 7&•991 HJ��E.itv.KUNRIDGE D'.RXVF, APN 769- 1.50- i
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
a,,.FI 1-t�1iL.�: I.l .lr 1.✓., t�•J Yf.s-/ li ..lM1 Si, Ii.L...
[.+.A QUINI'A CA 142233 1x11(:):f,Nix A;, 8.5014
USE OF PERMIT
SINGLE.t-.r4tWLY DWELLING
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PIFIRMIT HIM SUMMARY
C0N9.Y,CEIf(rFf N h^'W 101-000.418-UtiU 387403
i'T,?!. NR1?(I'11 HE 101-W50-430-318 1715 74
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BLEC'1` CAL.ME li)i-i�0�i-�b�0-e)Cli) 1�$aIE.9�
PT.I %ft31NG FU 101-(li)0-419-(){)Q $i 166.00
m-RONC} Ivf4.+rioll F Nf-12rimr) f of 41(} -24I W1ifi(1 S16 62
CRA1)3tQ'?,V, IGI-;liis .423-000 S.W. 0
I EV E):OPEER AIM -7r .HE, S t.907 6t)
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cc�y
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IIWAL PERMIT Vi F -S 1)UE )OSYj
AX,
RECEIPT
DATE
BY'
DATE FINALED
INSPECTOR
I :- .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
CY aj 1AL-a-,
Ducts
Slab Grade
— (/lj
Return Air
Steel
Combustion Air -
Roof Deck
Exhaust Fans
O.K. to Wrap
ZTporr
Ar
F.A.U.
Framing
_
7Tl
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
-Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Z3•rc/
Drywall - Int. Lath
_
%
Final
Final
_
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
>ir Connection
Encapsulation
Ms Piping
Gas Test
Appliances
Final
COMMENTS:
f
Final
Utility 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
Utility Notice (Perm) -