9711-109 (SFD)U
H
N_ U)
W
O M
� d O
o Z
OO
I— C:)
� U �
Wa
U)
Z
M
L0
N
ON
U
CL Q
C:) Z
LO -0
XW LL
0 _Jm U U
O
aLr)H
_Z
co 5
�O
a
J
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
674074 B 7%31 r 4`3
Date 1 t ' �' 1 Signature of Contractor l
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) 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.
(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 thaVif I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: f f, 1,4 Applicant—
Warning:
pplicant 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 inspection purposes. J
Signature (Owner/Agent) -+'� ' Date f d J F
PERMIT# CONTROL#
BUILDING PERMIT 9711-1419 Q
DATE VALUATION $190,41N9 00 LOT 26 TRACT `PjA V 6
ITE
f�
ADDRESS%i-]40CAI;RILLOWAV APN 646-420-01112
JOBS '
OWNER CONTRACTOR/DESIGNER/ENGINEER
T.D. UIiSFU DENE11,0PINIENT SPJ1RI S CQ? k.1.;H),Ul'i'iON
P.O. BOX 171:6 74295 RANCHO LA QUINTA DR.
LA QUINTA A W LS3 ft A QUIKI'A CA 92'2:S'4 it,
(.760)771-1941 CRI,N .`.. %
USE OF PERMIT t
SIT) a nn IM '
LOC 26, 'T`cR7RA A. PLA_K 2 - HE W T 7'PM-S NOT MCLUD- Ili0a K WALLS
OR K)OL. AIPP CRFIAT OF S2216.62131ik t: _sttlilrl, fAW.
�; 1?�t''.: �`f X99%
4F:C K FFEt71,12�4FOR MiA.TI-fK:;M. 1Jtt
St tli.'T,'(;YT 1, r<;)N�►Fit-F:�1 ttiN AND PIAN CI1FCK
t.l3S'S PIZE-PAID FT1:S
'1'0TAII, PKIiMIT 1F N WS 011 NOW
RECEIPT I DATE I BY J
INSPECTOR
$6,114_'14
422602
Q1TY OF LA QUA
CUSTOM�: c�N ITU;Ci[ ?�
F'VftC:t VATIO
r 1y.On1 S!
ESTIMATED C€;!.` T OV C'0N3 T RV(TfION
PERAD-T VEJE tii.r�i►lIIMARY
PLAN C44K'K FIi1-s
101-UM-439-3IR
3fytt.91
{y) Nr,IrRFT(;'1')ONFF..q
IAt4)(N 115-0{it)
Rn4tIf+0
�'l1l;t..i le'1.FtiriCAi. 1'l:I;
1 f; I -000-421-M
,°,111.54
E)1i�~f'ft1�2AI. [W%
11)14** -420-(60
5171,08
PI,UAIF) N0, iFr5i
101-0004119-000
SFfi(1 rff►
^'t'FdOW, m(yrFON TTI! - RF814)
10114M.2414M
41-00(!
�14,i►1
ORA1)12d0 t' M'
W1.000"923 -Ow
$20.00
114f.Flxi
225-400-443-3,12
$x.249.79
AR'i' IN }N-►F)LIQ FILAC I.3 - RJ:811,
701 -{)Q() -255 -OW
1«_16 .02
ART f`I f'lfitl.iC ftA.CV*S - Rz?.,41C 701 -(W -255.01W
4=1111011
St tli.'T,'(;YT 1, r<;)N�►Fit-F:�1 ttiN AND PIAN CI1FCK
t.l3S'S PIZE-PAID FT1:S
'1'0TAII, PKIiMIT 1F N WS 011 NOW
RECEIPT I DATE I BY J
INSPECTOR
$6,114_'14
422602
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— f 7-C17
Underground Ducts
Forms & Footings
12 1A Cpt
Ducts
Slab Grade
og (,
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
— —
F.A.U.
Framing
-
Compressor
Insulation
--—r
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
-
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
(J
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— G .
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)