0202-217 (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
701039 B HrC 11.3 110
,DateT� ,67 Signature of Contractor � �
C/
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 µ 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
S tion 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 Policy No.
wTATH,FUM 00u-161880-01
(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, and agree that if I should become
subject to the workers' compensation provisions of -Section 3700 of the Labor
Code, I shall forthwith comply with those pr 'visions.
Date: .. ,�^_ :, Applicant �„��0 L`
a
Warning: Failure to secure.Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, -indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. f
2. Any permit issued as a result of this application becomes null and void if fl
work is not commenced within 180 days from date of issuance of such Nr
permit, or cessation of work for 180 days will subject permit tocancellation. '
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 491 MSI Date -- A t
..�.
BUILDING PERMIT PERMIT#
DATE ` VALUATION LOT• i, ?0,2.-2141 TRACT
21134I b V 46 289vt
JOB SIT, It `✓ I �'
APN
ADDRESS
71$s90 RANCHO LM PASC U
64-9.4W-015
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M Lt.IQUWCA,X,
.iT.tJ11'dS VWT HOT -14610,11` c,
,68 ki_'iBERT STRM.- SSE 1.052
78-401 F M(3:[MAY 113
SAN 13WC 0 CA
LA QUIIVatA. CA 922,53
C160)7111X33&3 X33&3 CML -N; 41:12
USE OF PERMIT
$t�Fr�13 . LOT 46 3%1.01 3.A, F"i?� .2 I �` i�:3tiS 1dQ7' 111�P,t1l�E k%i �7C:JC"W Abel. a,
04 SPA ORM.WFAWAY APPROACH
TRACT C010TRUCTION 31$5510 UP
PO1b.C'1iPPATIO 3-6.150 SY
602.00 OF
COVISTRC1•CY]OP1 ME 101-P00-418, 00 81;b132, o
PLAN G")~11.'; CK rZZ 101_00",39-318 U36.26
M MXHAVICAL FEE 101-00-421-000 0.421-000 Sod.
WMI'RICA .. M10 101-0f)0420-000 $17L17
PLUMOR110FU 1.01.1000 119.000 $19,11211,
JTRONG MOTZiYN FFM - WID 101-000-241-000
GRADING PER 101400.423►000
ART IN PUI31 IC PLACE','- USK 270.100.445-000 $34.1,8
44:l,i_)':1.!A.'L'L.YL.iF.JFd b!•..:C4.�KA `h, 4.bJ-`� 3"l.�v.N .`.),:GAY 4uld.iR[':.�a�11.S.,�I�N.e�:i
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RECEIPT S•
DATE %F ':
BY-.!,
DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
—
Underground Ducts
Forms & Footings
(.
Ducts
Slab Grade
_ Z
Return Air
Steel
Combustion Air
Roof Deck
G cz
Exhaust Fans
O.K. to Wrap
_O
F.A.U.
Framing
_
-.9 ,� W
Compressor
Insulation
=3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
!L_
Final —
Final
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
PLUMBINGAPP OVALS
Gas Test
Waste Lines
_
ii
Electric Final
Heater Final
Water Piping
_ _
_ i _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
VVV
O.K. for Finish Plaster
Sewer Lateral
t,/�-
Pool Cover
Sewer Connection
!
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
-
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
i e
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
-
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)