0110-042 (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 andleffect.
License # Uc. Class Exp. Date
�314vc� 1131103
t h t
Date �!'r` `y ' ' Signature of Cont ar ctor,�
_ n ✓� V
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:
�() 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 f
permit is issued. My workers' compensation insurance carrier & policy no, are"
Carrier S't.�gE l UND ' Policy No.
(This section need not be completed if, the permit valuation is for $100.00•'oraess).
( ) 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,Jand agreefthat.if I should become
subject tolthe vyorkers' compensation provisions of Section 3700 of the Labor .
Code,r11.4 II forthwih conrply'wi h those,p{{ovlslons4
nt
Date Applica..;� ��iJa.1Ki I_ kl
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 ,Z.
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.author6 representatives of this City to ente upon,,'
the above mentioned. pr Ferty foF isp@ctlon,purposes.
Signature (Owner/Agent-i =� �,� �---Date
BUILDING PERMIT PERMIT#
Y�
DATE VALUATION "• LOT TRACT
6 28964
JOB SITEc�n•p� p�ry�Y
ADDRESSvYV<fi.CEAQO
APN
64sh-100-01.5
.,OWNER
CONTRACTOR / DESIGNER / EN (NEER
PM LA Q�:x'!,L'�i M
VWT HOUMN(I we
9968MM11.1T..TrE. 102
78-401 rt InGMMY 11.1
3AN.DW,00 CA 92131.
u. (,`aINTA CM 92253
x'160)"�71 a3363 C:BV. 4972
USE OF PERMIT
WNGLE
S14) - LOT 6.. $ 2C. WALL 4
FORMPATIO 9?
007M :1 COOT (?F Cr(NNW.RUt:`7',�ON
193,0 20)
101-•v1Uf2
LAN CHECK rt�>; ' ;- -4.39-318
i3N('�3l3td1 ` 1 . 101-000.421.000 �sB•Qo
t'j3f dyygg' k>�tjy,i�y1l, t'i`: •.!(0fl�t5�{0-X4.20-ryOi(�20
101-000-420-000
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/' 4FC i� k.Y�'i� b' SIe}7•8 J 8.':`i•V>d� � �•'S,t17 V A�rO:`e NJ
_: X53kt9r�1 3 .S�1L1 fl®N ns • uslo 36V -M)_24-1 -000
YkA:lDrAciny. 101;-000-413-000
3"r�B£f DPEfi IMPACT VE -0'
ELDE C1MT_. 1014ai?'t#439a313-v,600,00
rte •'�'
C 23061
C"f;A '�. N, f��U(,'!:'1C.)A? .; ND PLAN �'.PMCv.��
Cfl'IVC3L4t`.,:I"5fA 1eae`3 Pi
41,0),i3f,'
xvrpa, "MMT IPM -S Dug NOW
RECEIPT
DATE
BY).!
DATE FINALED
INSPECTOR
O 2
F
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
�
Ducts
Return Air
Slab Grade
� G
Steel
Combustion Air
Roof Deck
_ _
Exhaust Fans
O.K. to Wrap%/%
�// �/�/�
F.A.U. `
Framing
�2 ��` (_�
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8& Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
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 Pibg. Test
Final
;'i, -
Gas Piping
`y
PLUMBING APPROVALS--
Gas Test
Electric Final
Waste Lines
_ ""'
l iB'Z� S�
Heater Final
Water Piping
p g
/ �.,�,� ,�,,-;;, '
Plumbing Final
Plumbing Top Out
`°
Equipment Enclosure
Shower Pans
i ,`."
for.Finish Plaster
Sewer Lateral
Pooi;Cover
Sewer ConnectionL�.
�Z
Encapsulation
Gas Piping
Gas Test
2– C
Appliances
n�3 ;•„{
Final
r
COMMENTS:
• 4+fir - ._
Final
Utility Notice
_
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Z— `7 C2 2 �__