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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
6"740 74 .tB /31l
Signature of Contractor'f
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 & policy no. are:
Carrier Policy No.
S'I'r1 rE F1.IN,1. IV1095
(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 anymannerso as to become subject to the .
worker"s' 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'tthos�e,provisions.
bDate: r`. Applicant 1
Warning: Failure to secure Workers' Compensation coverage is unlawful' and
shall subject an employer to criminal penalties and civil fines up to $1'00,000, 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 S,t�ate laws relating to the building
construction, and hereby authorize representatives oft this City to enterjupon
ert
the above-mentioned property for inspection purposes. j
VSlgnature (Owner/Agent)` ,�' 7 Date 1 r.• 1 [�
PERMIT # CONTROL #
BUILDING PERMIT
9809-2ft
DATE VALUATION S260,917.�i{1 LOT 7 TRACT 28„2 9 _�(
1��/:= tib - 6� N
JOB SITE
ADDRESS 79460 tl,t LLE t R-1-Si{l
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T:D
sT',Iv:I.<w co�l�C'i't:.?C"1if��:
P.O. BOX rr> ti
79-1-95 RANCHO LA QUIN7:A R.
1.,A. QUIgrA. CA W253
i..ti, QU1NTA CA 02253
,
USE OF PERMIT
SINGLE FAMILY DWELJlw.R�ryc�:f�q
POOL. PLAN C''KEUK FEE (lCED 75%,41,43P, Ml r1.'1'I.N:l;1 f.;3�U�12�f >✓ OF
SAMEYLANTYPE.
CUSTOM C;ONST1cUCi10N 3.0-16.00 SIF
F�c3l�ClU13.A:z:iU 5810WO S
trriRAs?r'A1t1J>l'1 E;yl.Csp SF
E�rf11V NTIo) CIOSU 0.{31 CGNST1111117FIVN,
260.s947.213
PERMIT FHCDMRY
r.:OAIS'1',@iJiC'i'1Ci't FM 101,..000-418,000 31,203.0)
1'l,,AN C:KCKF03 1.0 8 �� •<�?
.'A413COANICAL FI<f 101-000-421-000 �i�-j.t9fl
ELEt`l RIOAL FEE 1.01 -00 -no -000
PLUNID.ING FEE 101 -000 -410 -NO Slt�3.0U
5170NO:lt40TIO;N FFE - RF 9ft7 1071 -t30{) -24!-G0{1
GRADING FSE 101-000423-000 �Lt1.t10
WIFRASTRUCI°iJ” Fi-:.1; 445-000,443-3342 $5.697.07
Al2'1' i.N J?UDL*1 PL.N0?8 - RE.S I; 701-000-2S54010, $402.79
9-r WFW L.. (f,)N%ZT_KUC°1'1'0N AND PIAN CNFC1t
$9-,108.04
Tfi;D'II'riL Pfi;9:iiW. I' Mi. DUE NOW
S8Q108.04
Alk -w `✓
ECFV 1
DATE /� �y ( �•`.
BY r r'^
DAT I LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs.
-2z A G
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
2� ,LG
Exhaust Fans
O.K. to Wrap==
F.A.U.
Framing_
L�
Compressor
Insulation
_
�' _.
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 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
7 i
Pool Cover
Sewer ConnectioncS
C (
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
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final Zi -:i g—
Utility Notice (Perm) / -
COMMENTS: