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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
C53 103 1/00
ate ` Signature of Contractor
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.
( ) 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.
"..TATE r LIND O f$..S+J-li=:i11r32>5i!
(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 agrjection
t if I should become
subject to the workers' compensation provision 3700 of the Labor
e, I If fort�with comply with those s.
Date: � y 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 thi's application becomes null and void if
work is not commenced wI�hin 180 :days from date of issuance of such
permit, or cessatio0r�fklor 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 St to laws relating to the building
construction, and hereby authorize repre ives of this City to enter upon
the above-mentioned property for in io purposes.
Suture (Owner/Agent): Date 3 I f 5
er
PERMIT #
BUILDING PERMIT k4�af� z.�a
DATE VALUATIONB�^2�1.Q1ti LOT TRACT
JOB SITE APN
ADDRESS 49-155 CASA DILL H10 _ ..
OWNER. CONTRACTOR / DESIGNER / ENGINEER
79-295 kANt. HO 1.A QLJrtfIA DRIVE 74-725 JONI DRIVE, 11A
1,,A 11ti1'FA C;:1 9225:1 TIALPYT D SE WIF C'A 260
(7601.140-9000 011L.•'� 355
USE OF PERMIT
Cn ifs ii�A.�atat 5' - �T./•utlt,( iiilA Riff .i �tfUS i' 1? iN ri.At.'•% Al
R'Iil:s•-Nl.A,`s'i'I�rt 1tJ:iI'I�v i'tta.N
I-i,uYXI.00 L, 1'3'
14,24011.00
PLAN CHF+: K FEE. 101 r li 1;4ti-3lN `b10530
C*ONSTRI ICq'*k0N Fr' 1 w -,` oo-.d 1 �,w100 10 (nI
NNIS 11A1'i1� AL FITC`i:10L 101 • (1 0 .I:! 1-tl00 $21f .00
,IzC f't,IC'AL FEE' -- VO(A. 1c11-iri)� 32ti Grin Si s.cii►
1'i.iJNWIN 10 1'EX - lli'. A. 10140U-419-000 $27,Ui1
sT 11;-11 j'Al . C }NtiTRI I( MON 11NiE;rt• RA n3 (11FT111: (i�t �?t;'i 1+1
EIPT. I DATE
TOTAL Ef'FIRMIT 94W.S DUE NOW
BY l DATE FINALED
INSPECTOR
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
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 - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
-
Set Backs
Electric Bond
- C
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Z_412F 102fG
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
CK for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
-
Gas Piping
Gas Test
Appliances
Final
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
UU14 Notice (Perm)
COMMENTS: