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LICENSED CONTRACTOR DECLARATION BUILDING PERMIT
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 DATE VALUATION LOT
Professionals Code, and my License is in full force and effect.a>.t�ti
License'# Lic. Class E%p. ate / JOB SITE 1+ 1 _ r
,¢ � f ADDRESS
f�9,�� B �1�� .+AA GJvQlf+ v f 30-'°+.i5 �".t���s�' F.�°1.V�iii�'�
Date/� Signature of Contractor ! - k d _ OWNER
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.
(,) -1 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.
°rA�xr KIND Policy
(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 is to become subject to the
workers' compensation laws of Californid'and agree that if I should become
subject tofthe workers' compensatioK.provisions olj ection 3700 of the Labor
Code,y,ll.shall 4rthwith comply with�thbse,provlslons.
Date:& -N ✓e %1 "7 Applicant D,, I_," Y_YO.E vi
'�. f�..✓ r ^� �.. 9 ryCr. ...-... . � pie � ti.'.r......
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.
s•
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, a�nd'State laws relating to the building
construction, and hereby authorize representatives of this City to enteit upon
the above-mentioned propel y f r'inspectionpurposes/ ;
� `R k
Signature (Owner/Agent^-e Date% /K)
Z
RiTHOW12 L:LIC
1?Ca nox. 810
1A QYJI%.`TA
USE OF PERMIT
PERMIT N
0201-032 TRACT
APN
FACTOR/DESIGNER/EN
298.5114-)
77,2-050-007
RX IN VA'.A7J,.�0.7:3':1 .."9 INC.
147-5 is ITWIMI :�� fYT_).1kVV*k,
CA 92,253 pHa6mX A.Z 95034
SFA. • ]XIT -04 PJAN PUB, r'.'ERMIT Osr $ NOT MCLUDE SLOC3
WAU,%, POOL OR. jZUV EWAY APPROACH
1'RACi t:1'a}3O R.fUCTION 3,284.00 sy
PORCIWAT 10 040,00 SF
C%ARAOF CARPOR'a 568.40 SP
(,"06'rO. (,7101'tffJZ1JMJ0.K'
s�`ONSTJIiUC:'I'AOH FEE
101-000-418-(3fJU
V03109
.PLAN CHF.0 K tRIF,,
101-000-439,318
$'826.07
MECHANICAL PER
101-000.421-000
S'::1100
ZL%C:T'`'fUCA_1, MY,
101.-000-420-000
$2fn.30
PUMt?tC1 fttoI
101-000.419.000
$1,40,00
STYMNO MOTION IEZ,, H&SID
101 K000-241.000
$20.09
OFLADli'I'O 1RIr
101-000.423.000
%20100
T')FIVE .C?M IMAx' IM, M4
$1,907.00
A18a IN .PUBLIC tPLACI'S"- RFAI',C 270-000-445-000
$1:2:;
t:
19MI` 't s'1'AL CIOWMIS.UCIrlt?g.AND PLAN (M-IRCK
ktAtlAYU
CITYOFLAQUINTA
RECEIPT DATE .;; BY DATE
241
. t
12001892.00
INSPECTION RECORD
OPERATION
I. DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
A
MECHANICAL APPROVALS
Set Backs
0
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
6 - _ C. '4
Exhaust Fans
O.K. to Wrap
G
F.A.U.
Framing
C7G•
Compressor
InsulationVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
p
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
Q.K. for Finish Plaster
'
Sewer Lateral
Sewer Connection_
_35_ V
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)