0110-044 (SFD)LICENSED CONTRACTOR DECLARATION
I herreby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
O ch License #) 1 Lic. Class t N\� E. Date
LO
LU1
-o OZ • , Date r^- w� Signature of Contractor:
U C:) OWNER -BUILDER DECLARATION
Ha r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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!ow.ner of the property, am exclusively contracting. with licensed
contractors'to-construct the project (Sec. 7044, Business &,Professionals
Code). >
Cl) () I am exempt under Section , B&P.C. for this reason
to
N Date Signature of Owner
ON
00)
Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O haveland will maintain a certificate of consent to self -insure for workers'
X W compensation, as.
provided for by Section 3700 of the Labor Code, for the
O Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
4,�0 U Q Section 3700 of the Labor Code, for the performance of the work for which this
ill' rn Z permit is issued. My workers' compensation insurance carrier & policy no. are:
I'll Carrier STATE ar3.814D Policy No. �v-�5•33i opol
O 5
(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'�pens/ation laws of California, and gree that if I should become
subject to the wo kers' compensation prowfsionof Section 3700 of the Labor
,ode, 1 �h6,forthwith comply witthoseht. pyo ls�logs!,�
APPlic—lU�!.�Tt
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
A. Each person upon:whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a.result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued•as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:.
I certify that I have read this application and state that the above information is
• correct. I agree to, comply with all City.and_Sli�te laws relating to the building
construction, and hereby a�itf orize representatives of this*City to enter` upon
11
the above-mentioned t ropert for inspection purposes es. f ���
p
}v;
d, -Signature (Owner/Agent)�� - -� t'�' L41 Date �• `' !ir�/
g t
�� fl
BUILDING PERMIT PERMIT# WO
01104)44
DATE VALUATION LOT TRACT
28964
JOB SITE
ADDRESS 6$t� J.?#.A1`1i. 101414VAN vaeAa'�
APN 64GO-(
OWNER
CONTRACTOR / DESIGNER / EN (NEER
9969111TIEW ITS, UK 107
78-4101 FWI GOWAY 311
9AN' Jl:,i 413110 Cik 92131
LAQXJDTrA. CA 42M
p60Y?'3`1t 3363 0MJff 4972
USE OF PERMIT
5 -Yr) 'i�r&y?t1�Jy4p�Tia♦3kFt',Iy�,,t.A"R�A'r3T�yDOES INCLUDE SLOPK WAL1.4
r p1..CnT yNOT
C f' 4�ICp7�1:"tL` �J'�S N'C41 i/, 7�.• MY.,7� [ 1]ky�8\�.0'7:!!r l'Y.
I�t'.FLt+<�i'illi?,A7'If� �'Ni.dz4 slz'
PARAO]WARPORT 661.0 or
USIMOAM COW OF ('110.91YMC110H
213,672-1,A)
"ORS'l`RUC'i`ION PEE 101 -MO -418-000 611933,59
#'I.AN GkDG.X F'fE.F • 18 $Ss$.26
WCHAl'11CAL ME 101-000.421-000 $9150
:.gFLLEyyCyy��:��eyy'��k�ykyyiss�tt„P�.�3,yF`EE 101-000-420-000s
E 1, 101-000-41,9-000 {�ll.p1t?
snOlaa monow Fn - .Rnm 101-000-241-000 $21.37
Cl.RAWN0IOU 141�(30t a42? ? sZ0,it0
r ,ifs:'t3''E1. OPR- t, IMPACT FFF $t,9(11.i1g-
ARS' Ili PUBLIC PLAM - NMll, 27V 0100.445-000 534.1,,8
YZE1DZPt`SIT 1Cilc>�CD �4.39.31S $1,t40t�.t3¢t
��
1 . C0,13 CRUCT101�' 07D :i>YLM' C
ILL)
$4,33-2-23
L83S PY0a?-PAKXT;TJ1S
41,900.00
CRY OF LAI`lfl'�TA •3'C' .'.'L:}M1"3S.UE'NOW
RECEIPT
DATE
BY
DATg FINALEP
L - UZ
INSPECT
I. ,
g
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_� _
1/� U)
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
12-- 1? g-(
F.A.U.
Framing
l� (
Compressor
Insulation
_
�,� - z - p i -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
•
Final
Final
/��r�Z
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location +
Underground Electric �t
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines _
Heater Final
Water Piping ;�IO
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
2
Appliances
Final
COMMENTS:
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
l;
Final
Utility Notice (Perm) ;
_`