0110-043 (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 %�} + t
Date Signature of Cont�racto.,° +r'
,,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Ccntractor'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:
Y) 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:
CarrierNU, PUND 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�tand agree that if I should become
subject to i he wprkers' compensation proWions of, Section 3700 of the Labor
Code, 1-shaJI forthwith comply Wiith'those provisions
4;.Date:1 1! `/Y� Appli4int I I , t ; . Mt"`
xs 1! >
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, indemnity
& 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 enterl up/on
the above-mentioned property.for Inspe(ction purposes. ( r!
,Signature (OwnerJAg@g)1 tt -�? ' .a s� — Date
BUILDING PERMIT PERMIT# 60
0110.043
DATE VALUATION LOT ' TRACT
:,e,- r.; . a f
J06 S -ITE ADDRESS W9��"l./fo7 .RANCHO oS�A �i'{��a�AN
APN 6W�'i9-IM0, 5
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IY'M U, QUNITA
IMARS Wor HOU811< G 199
9961S ,1:11`BER12 1r'. M 102
'78.401 FMGHWAY I 1 I
d.>`tMMEGOl CA 92131
1AQ1imn-,,A. CA. 922:5.3
(760)771-.1163 CMIA, 4972
USE OF PERMIT
StI'd -• LOT 7, BrI.:,AN 41;911. PERMIT s DOM NOT 1ta0,'IJO9 8LI:7CX 'tVA12.3,
4OO1.,fr�iPA OR DRIVfWAY APPRO,,4CH
TRACT CMIS3'RUCTflCYN3,;731,R-7
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WNSTR.IIt`yIONFEE ilii -0 4113-000 S1,4xi.Oa
;"LAN CHECK I?°EE 101-000-439-319 W1.91
MECHANICAL WIC 101«000-421000 SUN
Il.,UX:�'xi,"CAL FEE 101-000-42040GO $191.76
11.1 M9140WE 101-000-419-0 0-0 $19100
; YS2.itNO 111 0TIO'NHq $23.07
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RECEIPT
DATE
BY'
DATE INALED
SPE TOR
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F
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
-Q(
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
73Q?_Compressor
Compressor
Insulation
�.Z--�� p /
r
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
(—Z
Drywall - Int. Lath
C
Final
Final
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
-
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-2 X49
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection-
=per
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
/'Z�
(!J•� y
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)