0110-062 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that,) 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 # ' Lia Class , E'p. Date
701034 in � t I .. � I �J"� 1,477 7
'Date t } r r !r Signature of Contract9r %t `''' `�-. - " �% = -°
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
t.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pe'nalty-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:
Cartier �",rAT pUNL, Policy No.
(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 toa the workers' compensation provisions of, Section 3700 of the Labor
Code,71-sha forthwith comply with 3hose proovi�io ns
Date' ( f�Jl , /t+6` mjf. Applic N -J, � 7i
Warnin !IIIb: 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
construction, and hereby authorize reprdsentatives of this City to enter upon
the above-mentioned, property for inspection purposes. f
Signature (Owner/Agetal4-abate
- _ f
BUILDING PERMIT PERMTf1
DATE VALUATION LOTj� TRACT
JOB SITE
APN
ADDRESS :=wicyn� eltF`�?:T"fgR%^I
4):
OWNER
CONTRACTOR/DESIGNER/ENGINEER.
9%, 8 BIMEW'r SPIS,OiY,1TE 102
7 8-40 1 N MCUWAY 111
.3 � :D.T CA 9 131
LA QUINTA'CA 922.53
(760)7-11.3363 'C1iT_R 491
USE OgFgPERMIT
M Ay y
DMUMG
SIP0 • LOT 54 PLAN 3A, -PUNeI111" T)DES NOT ..INC1,W)e R33 ocr w A1.,L 3,
f%001AP A OR DRQ` SWAY AP} R0,&C X75% PLANC EEK VEE R+U,TrUC 1014
FOX 118SU.14ME OF MilLTIME PIA3' TYPE
TRACT !pt?1ti1S'!'RUC i 1014 "9,$55.00 By
SF
GAFiAMICAiRPORT 662,00 Sp
CONSTRUCTIONPRE 101-000-4-18-000 $1,0038.50
. PL;12 CHECLL'FCY- 1.01-000.4.3-9--i- 5� $214.07
MECHANICAL F R 101-000-421 -000 "21.50
f
F.T.ECTMA,L F1.117 101-000.420-000 $171.0
p1aYRit4ma Val 101,000-419 -000 1191.25
S'TR.I.OM MOTION ME Y ESM) 161-0i"R04W -000 $2337
C'3ftlLDINO MR ��1 <,Ot3G��81 R -00f1 ��ii.ttPR
DEWFA.CIPY . a1+• RACT ME $1,90700
Zia N., Punic PLAquo - usur zio-000- -000 �e14.fl8 '
_`� 11-11_ �-._._,- I •--• � a
.. -
i S
113 � 11 1, %��'RUCM 1103 !AAT€;+ PI.A9 MUM
$1,69 ).fib
vt�" _ L.' .. I , , a =0 PRE-11AID 1T s'
$0.00
g�f`j.1.:a;' - .•r
/��y.dy q�.'v���.,gp-y 'p���7.�` Y �p�{ }�,y�1�y�
' SCF 11'1A3 .! /.{JY<t.1Sd h'.4514,77 A.�9JSa _tqC� 8
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S3,6:Yi➢04
RECEIPT
DATE
BY
IAJJI2C)
INSPECTOR
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
11 INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
i! 1
Underground Ducts l l
Forms & Footings
Slab Grade
G G
% L G 2 ��5`
Ducts IC
Return Air jl
Steel
Combustion Air ja _
Roof Deck
_
�/L_
Exhaust Fans !I
0. K. to Wrap
—G
F.A.U.
Framing
Insulation
Fireplace P.L.
r�
2—_� _
Compressor I[
Vents ! f
Grills II
Fireplace T.O.
Fans & Controls i I
Party Wall Insulation
Condensate Lines ;
Party Wall Firewall
1
Exterior Lath
Drywall - Int. Lath
a 2
!
+1
Final II
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond qj
Footings
Main Drain, ;!
Bond Beam
Approval to Cover
Equipment Location 1I
Underground Electric 9I
Underground Plbg. Test '{
Final
Gas Piping I {
PLUMBING APPROVALS
Waste Lines�� /�. �� p/
Gas Test ;r .
Electric Final ^�
Heater Final i [
Water Piping
Plumbing Final i
Plumbing Top Out
Equipment Enclosure {
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_ _
�'- �2
Pool Cover ;
Encapsulation ! I
Gas Piping
Gas Test
VeM
Appliances
I I
Final
COMMENTS: T,,&7<.,7
0'2
_
j
f
9
i
Final
Utility Notice (Gas) 7���� 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) _—U'Z