0205-187 (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
`701039 BIIRC ,s',1 1/.x;103
f,f! rr
Date l /� '' # Signature of Contractor—
OWNER-BUILDER
ontractor
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).s, V,
( ) I, as'.ow6er of the property, am exclusively contracting with licensed
contractors to construct thk 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 maisitain a,certificate of consent to self -insure for workers'
compensation, as, provi(Red, for by Section 3700 of the Labor Code, for the
performance of the work for Whic;`,4his 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:.
CarrierfA'„ X F� t1Nr) Policy No. f166-kd�� 13-tt1
(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,ag'ree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those.provlslons:'" .
Date:
�e"JLt•'
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
1 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.
A ,✓>
Signature (Owner/Agent)'"" Date
BUILDING PERMIT PERMIT#
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Ca«9()9,.j,
DATE r VALUATION LOT 6 _-. TRACT 289f
JOB SITEAPN
ADDRESSS%-SICrwTF� S.d�'As�u�►��TJiT
IS�yPi QED
OWNER
CONTRACTOR / DESIGNER / ENGINEER
4YM LA QMtrI'fIN, L L
Jid 3 [� t 1Y, 1 DU 1t+lC:
z sy'.��a/,. .r 1`x1 r
78-401 :F FJIGIAI �4Y 131
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S.F1L11 D71.1 10 0111 9213 1.
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(760- 1'� 1 ^ J J 4+.�' aId+TS,.?
USE OF PERMIT
HC
SPY) % IX37 66 PLAN 3A . PERIMIT DOES NOT INCLUDE B.I OC.K
WALLS, POOL, SPA OR, DRJ_V XWAY,kPPR6ACH ,
!`]UiC-41' ;YA19 T RUCT104 .%55S.W(t
PORCr';lPATIO 5 .3tif S?
"Ef1MW10) COST 011 CONI TJL9.1J6,°eg.,Aon
.213,6 2,50
PNIZ&M FEZ NUTUMJ'3 4S Y
CON07 RITC TIO14 THEE 10imC100-418.000' �1.10311,so
PLA14 C.'H rVK rears 101-000.439-318 V: &26
MEC,i,°I.AM C A11 VFE 101 -CAW -421-000 S92.150
EiLfXTRICAL. FAZ 1:01 -000-4,20-000 00 $1'71.1 D
PLUIVID.040 WE 101.000-419-cXV 119112.1
Sj`RONO MOTION F99- '101-0100-241-000 PLY?
c11°t�fi PI11t"31TRE '101-000-4224-000 $1,S106
JOEVELDPE1<. IMPACT 1 • '�� 405, .00
.Air w Puai.11C PLACU - RES11`270-000- 5-000
4
LF25
$0.00
jU N 14 `2UR_.�j7A.1,P �tc.YDW1*0W
COCIFLAQUINTA
t
RECEIPT
DATEBY;
">
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
—4
Underground Ducts
Forms & Footings
( 6
Ducts
Slab Grade
- x7
Return Air
Steel
Combustion Air
Roof Deck
3o-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
02
Compressor
Insulation
p . _o v
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
— —
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
_
Equipment Enclosure
Shower Pans
-
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- _ Q
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Utility Notice (Perm)