0110-072 (SFD)U)
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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 iN Exp: Date
pp�yr' 4 gr f
�D' atei� �, ��° ,t^ Signature of Contrac �"�x: #�•`-`"'�
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
n
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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier VAIMe Policy No. fe:#S QdJ &�f11 3
(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'7 compensation laws of California+°and agree that if I should become
subject to tpe workers' compensation pro aisI S'of Section 3700 of the Labor
C+,r�de; I shall fprtpwith complyewlth 3hos prov sdons. i
tA)ate:(t .:�� E tl,., Applicant r � i �€ .._i
41.
Warning: Failure to secure Workers' Compensation coverage is unlawful aria
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.
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 withkallCity, and State laws relating to the building
constructlon, and hereby authorize representatives of this City to enter upon
purposes. q
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
j 78
JOB SITE
APN
ADDRESS 0- .M XAK3 10 L M.6EHC M)
64&40D-015
OWNER *
CONTRACTOR / DESIGNER / EN (NEER
996q 11:'#1,.��''0?'i` 113'3.1111 ala 102
78-401 F HIGHWAY 111
13d4i 'i7 ` rCb CIA 92131
LNQi;i3.R3 A C".,A.
92253
(760)771.336 CULS
49,72
USE OF PERMIT
;moi n T„CY7'.°s"a '�'1.As1 4D. PEWMIT DOMs NOT 1Na':LUM k31=1C WA1�1;. .
POOIAPA. OR i?WKWAY APP1iOAC'K 75% P i.A:t4C.HWX PPM 12i~:t?Uc:T09
P )R 1:1'SiYJAWCF, OY MUL7.IPL3 PJ,hlq, TYPE
TRACT G'ON°a" RUCT ..faN 941
f"41.1PA2`.IO 666.00 SP
0AaAC4is3CARPORT ` 846,0: SIF
J
ESUMNM COST bF
2)),747.10
FURbIrrFEE 911mj oy
CONO'1 RUC!'1tr1.1.%'1 E . M-000-418-000. $1,098.00
1"t1,,AN C;.I`i1XK. M 101-000-439-318
t�L>v�`l1 +1'IP'Al� ?Is 101.000P421-000
K1. YM'RI MAL YEE 101 -100ID-420-(100
PLiiMBT1, O FK$. 101.000.419.000 $m.60
C°'l1C IONQ MaI10H FE A RtF,SID 101-000-2A i ••000 $23.07
IMA.CD4?Jt.�,'% $20.00
' iOVE%7ER. IMPACT FE
ATd.' 'DI PUBLIC PL iCT0 • UPIr 270--000-445-000 ir7G V
u ®C
CI 1 bio ", i, IUM109 4113 PLA9 t3i3 C:�
$3,813.9'r
CITY OF LA v IM P1 MI -PAID MES
50.00
I'ENAI`1GIr r -el.
L.S
RECEIPTDATE
E
I DA NA j?1 SPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�— �_� p 2
Underground Ducts
Forms & Footings
Ducts
Return Air
Slab Grade
Steel
=
Combustion Air
Roof Deck
3_ -7 _—U
Exhaust Fans
0. K. to Wrap
Framing
/�, G
_ _�
F.A.U.
Compressor
-
��+ —
Insulation
�G� �f /
Vents
Fireplace P.L. ,
Grills
.
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
G/ ��—�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
�`
' U 2
Pool Cover
Sewer Connection
7 vJ
Encapsulation
Gas Piping
Gas Test 1
ZU — o 2— �_
+
Appliances
Final
COMMENTS:
Final
-
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Pl_
Sub Panels
Exterior Receptacles
G.F.I.
/—
Smoke Detectors /
Temp. Use of Power
Final
F4?: _ _ �Ll
Utility Notice (Perm)
_