0110-061 (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 „` �y1 Exp. Date
3t? t13 13I[!
^w. _. S.
Dater ✓�� Signature of C ntraE-"�'''
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( j) 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).
O I am exempt under Section B&P.C. fo�this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1(44) 1 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:
Cartier0ATH FUND 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' co ensation laws of California; and agree that if I should become
9
subject to thepworkers' compensation provisions of Section 3700 of the Labor
1 -i t ,
Code, ;shall forthwith comply with (th`oses row I - ns.
Date:,, � /T .(' ApPlicant.�if'•� �•��:1: _� �T:1?•..... 6:3....�...-.•
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 s
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 representatives of this City to ent r upon
the above mentioned propi rty`for,:inspectiion purposes. i
Signature (Ownef gen�DateV1�f�K
- .BUILDING PERMIT PERMIT#
(➢ (�63Q"s,t
DATE •VALUATION LOT TRACT
35C
JOB SITE , '
ADDRESS'
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.PM L. QUWrA
INC T ill 'i' YG7 l li9�iC3 I
9A68IM�I TI' r,IS=7512
713.4113 F]UGHWAY 71.7
T D.D EEG0 CA 92133.
L,ti q(MR-S'A CA. 92253
C; 60Y,771.xl n GrUlt 4772
USE OF PERMIT }
sm - wT 3s mAw ;€L?, OzRAT TJbn 140T TNCLUI7.S 11La1& 'Vdt LL4
1:100IM,A OR DktWKWAY•A PROAC-I3. 76%PLAAiCHECK PER Rl?DUCTTON
VOI'a., ISSUANCE OF ilRt11.7' P LLS PI,Ali 'r YPE
N
TRACT t<:OWST RUCTION ?,�35>.Pwtil ,Sp
FOR09PATIO 403.69 SF
i° ARA012XWORT 07,00 SP
P-
4
E6I.'1eW,IV-0 Cos), or, OOA4':'1M4,;'I'10111
141612 tb
CONSTRUCTION 101.000-418.000 $968.50
V2..i N CHEM, "S 101`-000•439-328 $1.90-69
MIz,CM41C.At. FEZ 103 -0 0-421 $89.00
�
d3LIMMICAL Y 301 -lit 0-420-000 $150.69
Ti�CiM 1,44onn. 707.1000-419.000 $ie" M
r=..
S'TRO146 bi1O'SIOP3 no - ' `io iot-6€ 6-23:3:00
CRADING HER fl�?��lS�i[) 4�3 C1tYl3 �1A.00
Dr��`►M'IMICIPER IMPACT FEE $I,9fi7.08
h
�. ^ �?1''iX' C Id I??i3iC'I'lcM:QTS'I"MCY,90.K.
a n�.
$3,:139.4€3
1. 133 :PRE-15ATD F'.rY.3
S0100
i i,Ii't CF L1
AL S J:r1R1.7.L8.S IFUS DUE Jl'UOW
$3,39.40
RECEIPT
DATE
BY;
DATE F LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs/�f,
Forms &Footings
Slab Grade
Q Z //J��
!�
G/ O
Underground Ducts
Ducts I I
Return Air I
_
Steel _
Roof.Deck
O.K. to Wrap _� a- _
Combustion Air !�
Exhaust Fans
F.A.U. Ij
Framing
Insulation
Fireplace P.L.
:- /L ..
—
Compressor i
Vents ; l
Grills ;I
Fireplace T.O.
Fans & Controls E I
Party Wall Insulation
Condensate Lines
Party Wall Firewall
l l
Exterior Lath
Drywall - Int. Lath
I I
31
Final i l
Final 7=,3—v �..��
BLOCKWALL APPROVALS
POOLS -SPAS
steel !c
Set Backs
Electric Bond 11
Footings
Main Drain i I
Bond Beam
Approval to Cover I
Equipment Location I
Underground Electric I
Underground Plbg. Test { I
Final
Gas Piping I
PLUMBING APPROVALS
Waste Lines G/� ��_.� �f _�i rS;
Gas Test
Electric Final ;
Heater Final i l
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure i I
Shower Pans
O.K. for Finish Plaster 1
Sewer Lateral
I Sewer Connection
_
Pool Cover i l
Encapsulation I l
Gas Piping
I!
Gas Test
_--3
Appliances
I
Final
COMMENTS:
i
!
i
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
C /
Utility Notice (Penn)