9706-052 (SFD)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
t Q:1t1 r 1 S ! 1311'.► i
Y Dafe1 �! Signature of Contractors !"
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
perf rmance 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:
Cartier 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 Califomia,,and agree that if I should become
, bject to the workers' compensation provisions�of,Se ion 3700 of'the Labor
JGode,
Vs
fortllwitt� omply with those pro°�visions. t
r/ ! y
Date: T f�� ' ppiicant
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 cancellatio
certify that I have read this application and state that the above inforr it
corr ct. I agree to comply with all City, and State laws relating to the buildirlg
co struction, and hereby authorize"'representatives of this City to enter upon
/Signature
above-mentionedproperty fo4Inspectl n purposes., (Owner/Agent) 1� Date
BUILDING PERMIT PtRM �i1ft t %2 �Vn 5309
DATE 615197 VALUATION %191,739.60 LOT 77 TRACT ��.151
ADDRESS 70-930 C' -VSA 641k. -L. H10 APN ' 646-312-015
OWNER CONTRACTOR / DESIGNER / ENGINEER
'J'1'; �;)1iSJJ'1°:'!iti` 3;'('I`:' i'r� �!'�11:1�� £�'t;fl•J�:1'1�C.if"I'lril`!
i1`0 HOK 70 -19294; iiANt. 1,10 LA. 4,Il:Ji.grA ()R,
LA. CAJIN'1'A CA 92 251 LA s.; ,ii.N'rA GA !r2253
t �t+i)'1777 1941 i:'.ltl.#1 20106
USE OF PERMIT
tit' i;1
'01) l.i,j'j 171 LAN IV 3-3
OIX II M �„ C O NSTRI tC 1 JON Z 2KI4.00 SIF
EiiAttalCfl�li'tElt€�1�4(:'1' 689.0o SF
ESTIMATED COOT O>4 CONS'!'JEtiJCUON
1911.739.60
t1k', .`` W1[T 6+6PENiff1tiOIARV
CCN E.VRlK*1riOP117 1a
101 -000418 -ON)
1$961.511
MAN r._'ff iCKk-'1 ,
101•{► .1139.318
$783.56
ME'CHAT CALJ::EE
$85.50
FLE( 1'.1UCAL..14?l:i.
11)1-110(')-4210-0611
;S 1421.16
111.1iMfi1Nt.) IrFIX.,
101-000 4WA01
$15fi. J
STIONO MOT! OM FET .. RHS.Hy
10) -0013-241-000
S10 17
CAW)u-'r. . J ?
101-000-423,-000
$2 0.00
1'NFRkH .1>'f44Lk 1V1W1 FEE,
225-00E1-443-34.2
:5i..4314,14
ART fN PUBLIC PLAC'!:3 , k.EME 70.1-000-255-000
S^24,.35
t'1.1AN CH CK VEJ.
0.11-0004W-318
-3587.67
SUB-TVYVAL C(I NS-1,11'f_k:.TlCIN, AW) PLAN (.31E:Cv.
LE.,�S PRtE-I�r'111)F1 E -S587.6
TOTAL PERMAT DUE NOW %,124.411
U� -
.
RECEIPT DATE BY-, DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap All
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - IM. 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 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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) �-
ELECTRICAL APPROVALS
.Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures.
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use -of Power
Final
Utility Notice (Perm) -