0205-201 (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
ev
Date �' ` 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 constructl the project (Seca 7044, Business & Professionals
Code). A.,
( ) I am exempt under Section B&P.C. for this reason
Date 6 ' t4 `^,yg 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, asy provided for by Section 3700 of the Labor Code, .for the
performance of the .work for which this permit is issued.
1�4, 1 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 gTAIIE FMIJy Policy No. 01*464991AOI
(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 provisionsof Section 3700 of the Labor
Code, I shall rovi
forthwith comply with those,
Date: ts'IW.ryE. 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•ismade & 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for 1npection purposes.
Signature (Owner/Agent) / Date
BUILDING PERMIT PERMIT//
DATE VALUATION $2.q3,67.? LOT: TRACT G
eC
G .
ADDRESS X9-490- b rt' AN001 b D! S�C�IVRI - JOB SITE
APN 40"15
OWNER CONTRACTOR/DESIGNER/EN (NEER
9968 MDER I' A f 9RI Tr 773.401 F 111GHW14Y h i I
0 A K 1)WKCA3 C. & 02131 1.AQUINI:A CA 92253
(760)TI IM5 ldl 4972
USE OFPERMIT
14IidaS F1M9. IIMBUING-
MBiNGSf0
630. Y.CY)X' 32 it L&W 30P.. 'I'ZPJ& ' n, ORk . M'CODE 73LOM
WATIA KXX. SPS. OR DMMWAY AMOA:C€1. 791A MW C. CK. VEF
RUDI.XVON D1IJ&'f0'h Ll9.'WU•,MWAN04O;ltSAMISF+LAIq'1W9
P—OWTVAU0 176.00.001? '
GA MAYMPM'1' a, i IV
PPP?"Ci'DRP. MCI MNAP.11
MYS7.`1f"'TL'"7'.5O ?MIR 101- 4AMID
""MICK M 1A0�1-Wp�4y)-,,(39 $214,0
�3qq}}18^
iVJ/st..rlE[Ad.Vifv.72.re-.l�C:+ 1L� "'CC±/F/�'^if..lt-:�If+✓ $9,2150
I?D dIAT'4T91 �•1�JrfiD S191.25
STRONG MfYIIOI+I•; M MSID 101 -W0,241 -0W $21,37
s3AtA1*4WH q 101- A-423-000 $15.00
URVAWM. 1UPAC111, EVE V2,401.00
AA,T Std IUMC PJA S - TEM 270-OW445-M WAS
.
WNSTRWrIM AND PLAN MOM
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LESS PRI-2-YAMPEF19
' 'CAVA l.iKIMUT M.W81JC!'ujiSl.:NOW
MiN1.04
JUS 14 2GU1
CITY OF LAQUINTA
FINANCEDEPT
RECEIPT
DATE :
;BY.
DATE FINALED
INSPECT
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
- CJ'L G
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
,p — % a Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
- p�
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
1
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
�f �V
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
_
/
Gas Test
-�
Appliances
Final
COMMENTS:
Final
Utility Notice
z
(Gas)�c>
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
Utility Notice (Perm)
;L -
L/