9809-204 (SFD)U)
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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 /�' Ex . Date
%r 1
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/atfir j Signature of Contractor
OWNER -BUILDER DECLARATION t
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.
w'S'ATE FUND 137 LIN5
(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. he Labor
��jjode, I shall forthwith comply with thosejprovisions.
dDate:lo+ ���� 11 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 enterl'upon
th above-mentioned property for inspection purposes..
Signature (Owner/Agent) �r ( Date Jt f J
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PERMIT# _ CONTROL# '
BUILDING PERMIT
"10-204
DATE VALUATION $266.917 �(� LOT a TRACT 28-2,95
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JOB SITEAPN
'ADDRESS 79.4020l,.iCLLE M1iSA
e.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P.O. BOX i 7 iG
79-2195 .RANCHO LA. QUINIA D.R.
LA QLJN'-FA. CA 92253
LA QLJ1WI A CA, 92,253
USE OF PERMIT
yfNGL E' FA IN4 I L V 0V►dE.L,ONCJ'
`v.t7r3; PLAN Mi. LOT 9, PERMIT DGUS NOT rty+J;i,:t3M 13 —KO WALL O
POOL PL.4IJ CKHCK FF. i!2Ef.)t. (M) 75°,1'0 EU3k MU:,,`1"!P'J..P, IS`aUANC6 OF
SA1bit, .IaLA.i�f 't`s'FSI:s.
P0R(ZH/1?A.T10 580-00 STF
CrAf2At dl(fCAR.C'GiC:C 693.008F
kf;S'°rUNIA, TEW MST OF CONSTRUCTION
260,917.20
CONSTRUCTION FE13 101-000-41, i-60 i $1'2103.00
PLAN C.iY(X FE M -WO -43$-3 .g S247.01
MECi TANI CAL #%aKix: 141-000,421.400 S12 4.00
p:LECIRICA
PLt;iVlt "fNCi fi'T F 101-000-4.19-000 �i 't.iitl
."? ty6141i91G MO TON M-4 - RE $10 101-000-241-000
GRAL)ING FM 101-C' -WO-423-000 a�J.tui
!NF ;FEE 225-0tiG-44.V342 55,.697.0 i
AR.T I'tq PUBLIC: PLACES - PJ."�SJt t 701•-000-255.000 '$402,219
SU.111T)rA1_-t-'•0Nti'?'RC7M' CN AND PLAN CNECF4
LESS. PRl -PAID TEES
0.M
'FUF 1i.,1v.EIRIVIVC #j'.9;_V� DUE NOW
$8,108.04
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BECEI T) Cy }
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BY t�
DATE Alk
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
C(Z'• _ �
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans'
G"
O.K. to Wrap
�/ G=!—tG L
F.A.U.
Framing
G`
Compressor
Insulation
2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Q
Final
Final 171:75-
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
_
.- C
Heater Final
Water Piping
Plumbing Final.
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_z 01,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�G
Appliances
Final
COMMENTS:
Final
_
Utility Notice (Gas)
!-1
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)
-� _