0110-057 (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 �t �fxp. Date
Date �F Signature of Contractor•u. QkJk {
I"', r f �✓ "c' r'„�
r
t OWNER -BUILDER DECLARATION
I lier'ek5y 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:
, V 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:
Carrier BITAU FVND Policy No. 0 �- 31DO.aiS
(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 wo'rkers'•compensation provisions of 'Section 3700 of the Labor
CodDatee I•,sal�l fo �li�{hApplipanti ly with kthose�povons ; 'J;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 hist
application. °
1. Each person upon whose behalf this application is made & each person ab.
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 mill 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 tAancellation.
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/Agen%4 + ' ` f DatetE
BUILDING PERMIT PERMIT # VO
DATE VALUATION LOT 01.10-057 TRACT
.r ,r'-. f �"'i . ✓w ., , .:7. r 59 28964
JOB SITE
APN
ADDRESS i'qjQF� ilk. MM
_10
t3�i.'-E%S,eg
OWNER�
CONTRACTOR/DESIGNER ENGINEER
Swyy .Qq1r—A
TRRCgSWETV4igNG K90,
9968 kYADE T all.IS'ITiTE 102
7 8.401 F 13TGMAY I I I
,YAWMEC30 CA 921.31
''GAQU:INTA CIA 9225:3 _
(160Y171.3353 CIBLO 4M
USE OF PERMIT
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1 ASelEM M.y IT)W 'Y-11
SSS) " 1,0", 59 .PLAN 4DR. PEPI .IT L)i?2,' NOT INCL2iM .8110C:Ik
WALIX, PIC)OIA. PA 01P.-DRBILWAY APPROACH
.�,�.W-T CC11•i9'PIiUC TION:081.00 OF
PCdi,.� FJPAT10 666.00 Sr
"N 134d,t36! ;�;a
230,74730
T.'„�'RA41TRIAM SUMMARY
CONST1xAWTION mr, KI'l-000- 18.000 11,098,DD
h.. u cligm Ira $901,01
911 C1is�a3lt`�ti1� T 101-0f:0-421.-000 .336,00
R'LEC TR1CAJ, PEE 01-000-4213-000 $283,76
:'IoUMDTN0 F9B. 101.000-•19-00t, %PK00
J"l"FcUNO,DifCTIO 1re`�i t3.t:Sii� 1-Gi�6I� #-s`3?"!f3 a�.f33
GRADING FRE ��q."�itJt1-�2�vc.)fi1! WAD
LIZVEi 93PER )Nil~?ACT IU t 1,9.07.ti0
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$4,4W,71
RECEIPT
DATE
BY
DATEF AL D�
INSPECTOR
J!
INSPECTION RECORD
OPERATION
DATEINSPECTOR
OPERATION
DATE
INSPECTOR
BUILIDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings }
Underground Ducts
Ducts
Slab Grade I }
Steel t
Z z$24pj�
r
�9
Return Air
Combustion Air
Roof Deck ! i
,Z — / - a 2—
Exhaust Fans
O.K. to Wrap i t
��� Z
F.A.U.
FramingI
Insulation [ i
7 Ci _
_ _
!
Compressor
Vents
Fireplace P.L. i i
Grills
Fireplace T.O. I i
Fans & Controls
Party Wall Insulation i.
Condensate Lines
Party Wall Firewall !;
Exterior Lath
Drywall - Int. Lath
jl
] !
Final
Final +I 7— l o Z ,,_�
BLOCKWALL APPROVALS:
—
POOLS - SPAS
Set Backs j ;
Electric Bond
Footings i i
Main Drain
Bond Beam j I
j Approval to Cover
1 i
Equipment Location
f!
Underground Electric
!
Underground Plbg. Test
Final 1 }
Gas Piping
PLUMBING APPROVALS
Waste Linesf� • ZU. U�
Water Piping i' `
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure.
Shower Pans
O.K. for Finish Plaster
Sewer Lateral{ ;
Sewer Connection ;;
6-
/�/
Pool Cover
Encapsulation
Gas Piping s
Gas Test
Appliances r
Final
i'
COMMENTS:
4
F:..
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS '
Temp. Power Pole i
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures i7
Main Service 11
Sub Panels
Exterior Receptacles ±t
G.F.I. i( "
Smoke Detectors
Temp. Use of Power ;
I
Final i ! —.
Utility Notice (Perm) If ZO O'`