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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.
{ , sl;icense # Lic. Class Exp. Date
714188 B 10/31113:)
, ,fir-gy- ,.
ate' Signature of ContraEtor •.
OWNER -BUILDER DECLARATI N
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).
( ) 1; as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) 1 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.
GU.L D!CN F1.(:L.F INSr, NVC 54406. (H)
(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 should become
sub' ctto the workers' compensation provisions of Section 3700 of the Labor
C dir ha I rt _ comply wit�,th5g rovisio
ate:/--S'Applicant�i
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
con ruction, and hereby authorize representatives of this City to enter upon
th above-mentioned property f inspect purposes.
Signaturelet
(Owner/Agents
BUILDINGPERMIT PERM'CONTROL#
DATE VALUATION i1QI�*�3Q)-.iaE LOT TRACTX713 7
ADDRESS JOB SItE :? 1 d;: ,L3I.Il, LANE
APN 604-•37:7 006
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i; NTLIRY,
133 So, "I)°' ti i i(.i:I�'.f', S fE. i2()O
1.333 SO. "U" ,STkLE i','STE, <()u
SAN 13�T{:tvr�1T1a1'RiC► C:�i. �r240l3
SAN}3F;1ZNARIXN(j CA 92409
(Niy't',►3f4.l-CUf1'7 C"iZL;+ ',120
USE.OF PERMIT
h"ifiLY DWELIANG
SH), ii.dkN 26, LOT b. I>ERdtfi i' DOES NOT iNCLUOL BLOCK WiU13 flip
TRA(: i C0NSTRU(rV."NL 1,2-45.110 F
P0RCHfPJ:1'C0 36.0 til
GARAGFJCARP0 f 63lt,lili sw
I: N'TUi�4��:"9'EWCOST O d:�;N'N`1r�:€71 T:€�R
1140.4341,34)
Mama FEF, ,4ETMfWARY
Pt,,AN CHECK FFY, 1014)(tO-439 3IK - S4163.51
{'C7�fSTFt fr`,'pT��t�f }��tr i Cl a -�-4 i �-t)(kl $55.1.(1(•2
i41!?.C,` 0"NICAL FD? 10.1.-t?(10•42!4** $17.0si
LLE ,:'rtUCAI.. FFC 101 -OW -420-000
PLLFNf"tN1 G FIEE 11,01400-419-M)
T'i ItG�Tt NIQTI(.)N FPT, -; _ .Ft,30 101_-000-24) -{}EH) $m)4
GltADING 14.1-11E 101-000-423-000 520.00
113FRASTR(K,' f URE JZEF 2253 -OW -443-3 42 $I,793.91
�9
-� '1 4 (;.:(.1I+ISI T'.U( 1'10N AND PLAN f„T-11'/CK
1 )4.16
L,I S PRL
$0.00
TOTAL PERMIT FEM ii4lE NOW
5LM,14..16
'
RECEIPT
DATE
iBY'
DATE FINALED
INSPECTOR
4
USPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDING
APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
/
Ducts
Slab Grade
o -
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
Framing
/ - 8'
F.A.U.
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 s
SLOCKWALL APPROVALS
POOLS o SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUM MNG APPROVALS
Gas Test
Electric Final
Waste Lines
042Heater
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
0
Appliances
Final
Final
Utility Notice (Gas)
E LECTMCAa 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) li�
COMMEf1 TS: