9807-264 (SFD)LICENSED CONTRACTOR DECLARATION
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
7141 & B 101131i99
Dat r -Signature of Cdr _r
✓ J '
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
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 carver & policy no. are:_'
Carrier Policy No.
GOLI)EN EA.' CLE U49. *14we 511 -40168 _09
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code; 1Aall forthwit omply w t e dvisio
Dater plicant .,..y
Warning: Failure to secure Workers' CompensdWh 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 r
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 dayswill 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. %�`
Signature (Owner/Agent .• J DaIVA te!�'�
BUILDING PERMIT PERMIT9807-264 CONTROL#
DATE VALUATION S9;,t<iW..-,l LOT 4 TRACT 713 6
JOB SN5_'Lil
'B5_40;iCI-WRt LAN R:
APN 604I -.►75-0.5
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PY'1 f!V 1 l"E
t_.t��.,.t�.� s~.�.G.,,s�,..,..;l1t9�R�,..,!'!;1'��,.,
���.. 1`1 T `V !L' r �x•tnrtr t. Yr'i '`
15:35 SO. "U" S 1 Rf� 1, 'Tt- l'2(}U
1535 :ice. "f?" Sl'Qi f .}?'C, i'I'L. 0200
SAN BE-10iARDINC) CA 42408
SAN fif;ItivARI)INC► CA 924ON
(909,j381-600 C13(t 2120
USE OF PERMIT
-'ILR i ikM!1.Y f $ WEIl. N'i
SFE), PLAN ABR. LOTS, lii i2.MIT DOB NOT 1I OUq)i::1 LOC WALL.
OR POOL,
VkA/71 CONS 1711 UCTJ Odd 1,445.00 Si:
0Al2AGEIC.AkPORT 635.60 SIS
AE'S'�•:t;l.1LUTI :BD COST OF C'OINSTRUC-!'`SM
Y'�f'Rli�a'1 ll'6. �+J �rJI�IOYL'i.I�Hr
.
PLAN CHECK FIR 10.1-000.439-318 S504.98
CONg'I'RUC"f` ON FIFE t.0 f-0'!'.)-ct 1 }I -i _ 0 G59Q,tq i
i41f�CNIANICAL 1-tsti 101-000-421-000 9�f^tit
f1_F�("Cltittfll.ffsF li)1-tKit)-411aU-(Ia0 �i11.-rll
NLUMIi'fNG FEE 101-000-419-000 S 1480)
' 'TR.OWO NfcY JOW FITT - RFSID 101 -OTIC -211 -DOC $90)
r;l{AJAI G 1;1�X 101 -W -423 -ON &20io
1fJd ltAS4I'1Z1'•fC:`1`U12.[, FEE 225-000-443-3-1.21 2 tii5.<i+i
p
4 P@P w a •
1- ti(]F�••. " rAif C0 �"1'R11C°'f`L(:1N"aNIDKALESS/�N �r'1- E K.
i,Rb1
PAID E0
'F(YI'A:li.. iP1F,9tM111' Vk+ES DIIiH::gI4' W
1
RECEIPT
DATE BY
DATE FINALES
INSPECTOR
NSPEC` MIM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLD G APPROVALS
6�1i ECHANCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck (_. (16 -q&
Exhaust Fans
O.K. to Wrap 12 -/8- Tr
F.A.U.
Framing Z - a -
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 / 9
Final
Final d
BLOCKWAL L APPROVAL'S
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location .
Underground Electric
Underground PI . Test
Final
Gas Piping
PLUMBWG APPROVALS
Gas Test
Electric Final
Waste Lines1c--1r44 r-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection e - ytjIf
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELEC 1i=ALS 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
Utiliy Notice (Perm)
COMMENTS:
TS: