0205-199 (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
70,11039 R HIC rem,;, 0 W nP20
Date 1 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 -U Policy No. 164891 .1
(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, I shall}forthwith comply with those provir
slo �s.,. y
Date: ��' E `t pry Applicant-
Warning:
pplicant ;
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application,is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informatiomis
correct. I agree to comply with all City, and State laws relating to the building`'
construction, and hereby authorize representatives of this City to enter: upon
the above-mentioned property fortinspection purposes.
Signature (Owner/Agent)`" nr'''"� Date
BUILDING PERMIT PERMIT# VO
DATE VALUATION LOT TRACT
30 129964
JOB SITE •�y•�-��Ap
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Ph11,J'i QY3"iY rAI i:� L. Com.
T111 A,P+341111 WEIrr Y;fOTbi ING INC:
9!A, £8 11M7haRT S S'RIEr!'
78-401 F AUGITWAY I I I
SAN Da`i OO CA 92,138
LAQ1'.iNTA. Ole.
C°769)711.3.63 CWt V 2
`
USE OF PERMIT
UNOU FAMILY DWRIA.M0
�
M?D a Low 36 r��l,.e4y�i10'%' 1t4CY,:i3l�1y5TS::E�11L�y0q
o➢�•Cl@l!: *.�v�M(th��lTT �I.!�Ai�+;�
��Cp:�a��y q�y��
Vitt U,,S, PW14,SP f5fL OOMW A:A. t'AWWA(iaSL ?w5 �", 9LA*N �.r.F.?.I:,h.41..K'JW ; .
PJW1Xrft01%1 DUE To AIR.IVU LSaE)*A.OF SAME FL4U9 7t'Y'KS
SCS i E 9lix�' 37AAJ0 °.i�+
OAKWHICA101OR ' a s1?
O�C7�tS'.g.FC'i°1:CkId):�3 1138-•n0�•1t� �?,�3�:Se}
18
NAANCTWIC FEE 101-000-439-3118
ENAMCA$, PM HH - 4211 B.54J
1 3C`1` ti:t�1, ��3it 1631�{t{if$� d0 (!4i SIVA$.
�.{.�.�4i3S1�•�:� If�3-db9�A�19 $1?dA.2�
'
:5°i1iC3NP MOW?[8i8 FIR - REW 101.000^241- $10.19
G RAIM0 m sils.00
. M
nSM TOTAL CUN"`R1sC," 8' ON AND PLA14 CHECK
$4.041.37
F,�OS ,PROE-PAM VAW
WXYP
VUH, NOW
JU N 14 ZOR
CITYOFLAQUIMTA
FINANCE DEPT C -
RECEIPT
DATE
BY
DATE FINALED
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
r
Ducts
Slab Grade�_
_
ReturnAir
Steel
Combustion Air
Roof Deck
–
Exhaust Fans
O.K. to Wrap /p . O2_ _
Framing _
F.A.U.
Compressor
Insulation2,0',17_
py
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/,19 p>
Final
Final – Z�—
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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/�
!i
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
_ – v
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
_
Sewer Connection _
Gas Piping
Encapsulation
Gas Test
Z
Appliances
Final
Final
Utility Notice (Gas) _ g, — L
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 242r
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles ✓
G.F.I.
Smoke Detectors
Temp. Use of Power
Final ,...
Utility Notice (Perm) Z
COMMENTS: