0306-495 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
c14 W Professionals Code, and my License is in full force and effect.
O =)c ) Licensees# q�?,z Lic. Class Exp. Date
q
Z Imo, Date Signature of Contractor t g4o•/
ZOOS°
J U C:) OWNER -BUILDER DECLARATION
WaU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) I am exempt under Section B&P.C. for this reason
LO
O N Date Signature of Owner
N
d Q WORKER'S COMPENSATION DECLARATION
C) 2 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 U compensation, as provided -for_by Section 3700 of the Labor Code, for the
m_ Q performance of the work for which this permit is issued.
Q() (...) I have and will maintain, workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
�* Z Carrier STATH :F`ltRD Policy No. 110MV-03
obZ)
O
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 not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I shouldobecome
subject to the workers' compensation provisions of Section 3700 o he Labor
Code, I shall forthwith comply with those provisions.
,Aal&.' �.!r1r` c�._5 Applicant "V ° .._.-•.._ ��
Warning: Failure to secure Wo�ers' Compensation coverage is unlawful and
shall subject an employer to cr ininal penalties and civil fines up to $100,000, in
addition to the cost of compefsation, 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.
44
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.
r`
Signature (Owner/Agent) �) �° `� �%"v"1" --,' Date'
BUILDING PERMIT PERM'0A-
DATE VALUATION 13".13.10 LOT 123 TRACT
JOB SITE
ADDRESS 43.611 COVIR A u 0RO
APN
J
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1,A QW!'A OUNB9 ::.SO
Ctofam;3° ic-014E ]Dy:Te
5,003 CALIX WftRHA..�`� ., ME. R-3
C A..rieE
PALM,: & 101ATtjas CA 9226*4
psi SPRN S k"A 92263
{ BIX X18167
,
USE OF PERMIT
�,i 1J • 16,J! .id:t, lett•0t ,�'t'a �,!'t.t6 ,ii. C'I'.•ftft _.d !s '?t:. -Y Y tJ .. Gr ?,.{.J?.JP
i
'f'DaAVT CONS71i: CTIM a,318.90 By
PORCI-I/P. TILT ''j .15.0 ;1i'
��.1.keAC9F°lC.�l..t'ct'�.�sy�' 4•�'�.L� :'�
i J
�.;sm!%,m) f'.o' P1 or conti?.:sm1';x'yoji
LK..3I.340
1'ERM'rX1i111 ssumwv",
CONSTRU ON RE 101 -000.418.000 R'Jd9,:ip
PLAN C;H n: KBE 161-000-439-$18 $87.0-
WC)rAN10I.Ad,FEE 101,000.421.000 566,00
3 iXIICTI;01. 441 IMF 101-000-420-000 .<,XR7
tQs 1 U. 01..400.41.9-000 MUD. .
!r'u nn o. mv.'ICON FEB - mrsID I'll -1 ob-,za 1-000 $1.163
101_000_4 3_000 ffit -001 .
IMPACT FeEL7.
e• TZ T.A. , c:':ONS'; . ' �1 ��D1� .f�'a� PLAN v1:� CK
$4,1.90.30
AUG 11 20QM1.1; IMNIMPFIES Duk NO
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
JY
BY t
D FIN ff,INSP
TO
1 .{
.�3J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 9.–//_
Ducts
Slab Grade
Return Air
Steel 3
Combustion Air
Roof Deck
aust Fans
O.K. to Wrap
F.A.U.
Aft
Framing
Compressor
Insulation J
Vents ✓
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
012
final
Final
BLOCKWALL APPROV
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 APP OVA
Gas Test
Electric Final
Waste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
of Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 17 -
Low Voltage Wiring
Fixtures
Main Service ,
Sub Panels
Exterior Receptacles oe-
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
;/A–N,�' �,
Utility Notice (Perm) /—:-/
COMMENTS: