0110-058 (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 # T Lic. Class Et p. Date
Date � #.� �It1 .Si nature of Contractor~"
Signature
' 1,
i:.
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:
S/) 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:
Carrier STATp 3f--UND Policy No. 63s-110.0001236
(This section need riot 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 lbe workers' compens ti'�n provisions 1pf, Section. 3700 of the Labor
Code, h,'sh ll,fo hwith comply with �Ypos prou�slo 's�
Date: ffy " r/r':?i Applicant { l;•�c`�o\is, I/qs./ , 46,+..a --.
Warniing: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is, performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any.permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above,information is
correct. I agree to comply with all City, aed State laws relating c, the buildI g
construction, and herebyn^authorize representatives of this City to enter upon
the above-mentioned.prob'etrty for inspection purposes.
F� fff 1 j'r � j
S nature (Owner/A`gent -' } � �:p �r �l '�4•a Date �►r '
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
S1.SYJA. 21%) 3 3 ZR964
/' f 1- f
JOB SITE
APN
ADDRESS 4)l , i�10 ,Aj� i� r��at.
644,40"15
-OWNER
CONTRACTOR / DESIGNER / EN (NEER
PIA I,,#',.QUID rA
l .4" WWf'JJC)UMNG INC:
9.86x8 }1IL ERY UT.,3.LUB 102
'78-401 F M:F1TWAY 17 3
BA14N&4.faO CSA 92131
LA.QU3NTA C"A 92253
060;7`"a1X336+:3 �CBXA X4972
USE OF PERMIT .
:y il3 LOT 58 Pi~ All 2APL PERMIT DOP3 3afOT INCLUIDE 81,43CK WAL L4;, �
P00USM OR, DWKWAY APPROACH
TRACT CONSTRUCTION 3.230.00 OF
VOf'LMIPATIO 40100 SPI,
B27MIATED CO&T OF IG.°ellNUMUiMOR
V". A1.2
PRRYWC:619W S! 1"1# fit y
i:X' YMT, fRVCT]0N ME
PL A14 rs"?iilECK 9 101••000-439-318
MUL`-1.1 'N1CAI, FEE 101.000.42.1-000
XLW Pi$I AL IME 101-000-120-000 X899.89
PLt3MUTHO DYKE 101-000.419-000 90M.25
f 01:-:00-249 •-ODO 1J.36
:T.tggi � i? Cf L 10,11 kJON-123.000 920,04
.�
rill!
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UU 6� gf'115ranr .l,, C "�MIJ if 1.€d.UCTION ,(a M P:t'..AW CIM.&I.
:M P.&PA1:f31F
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CITE/ OF LA VU1 1 fA
FINAHCp r- T.
Now
9- 4, 1 M , A
RECEIPT
DATE
BY
DATE INALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings i
Underground Ducts
Ducts
Slab Grade
_�
Gam,.
Return Air
Steel
Roof Deck
O.K. to Wrap
�--�� v ZS
C_
Combustion Air
Exhaust Fans
F.A.U.
Framing
_� Q_��
Compressor
Insulation=3.—Q
Fireplace P.L.
L_
�%
Vents
Grills
Fireplace T.O.
/
Fans & Controls
Party Wall Insulation ;
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
G�
r
Final
Final
G
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 LateralPool
_
Sewer Connection _ c�� t _�
f j %
Cover
Encapsulation
Gas Piping
Gas Test
Appliances ---
Final
COMMENTS:
Final
Utility Notice (Gas) �' % r, -
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) : -Q_6L 0 �_