0110-066 (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 j S� Exp. Date
7F311,!
Date ` 3 111, : 'Il Iiia -
!, Signature of Co t a�c9tgr
t-
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
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'
cdmpensation, as provided for by Section 3700 of the Labor Code, for the
a 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:
Cartier iJT#k'°E F(YND Policy No. W -000 W5
(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 oa !Section 3700 of the Labor
Eode, Ih IIJorthw'th comply with those,p ovislons� )
Date:' t=) f . Applicanti• j 1i �114.�.` j epi
--
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.
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 authorise\representatives of this City to enter upon
the above-mentioned proPefrty foriinpec ojn purposes. J` J
Signature (Owner/AgetJ}(�: 15~ -'t' jy- d� �"' Datef
BUILDING PERMIT PERMIT#
+�
DATE VALUATIONnyI�y. LOTTRACT
t49.1,SYM-20 50 28964
JOB SITE
ADDRESS 49.4() .R' jMq�.Uo 1,tA
'
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
r-%,5LhQU1HT-A
TRAN9 WEST HOMING WIC
;190 R Is"I ILEI 13" E 1 Q
7&401 F' tG? Y s 1
Sa ;R 161 � 92131.
t,A (�jKNT,ot CAa 3 922
pYSJyni-3363 CF3 4 4972
USE OF PERMIT
Sfit - Y AC' !�A PLAN 1.A, PERMIT DOLPSNryr fiNC1,0rAZ 8LQCK WAIA.%
3'OOLP3&"A OR � �.HN,C*WA,Y APPROACH ;,ti
TRACT CONSTRUCTION
t POI':CHPATIO 5,6.00 SP
r 0JfiaP_AC'Y.g'tF•aARPORT / 64&00 SF
�:30�bFi9�l�i�i:T1C�Tr S�� 14i1 a�)�1•�1.7 ��f?�4Q . �951.�0
�Y3,,Ai+1 l..tYs;CK FrOZ.
MXC1'IAWCAL 13 1 t 2 �t8t104421 �i f,E1 q%. $t
F7_XC7'1;i.1C".AE.1' F �;f$ ^�1�lt�- 4 't tC�() 9157.48
P1,UMt1:1Ti70,FIBE }01_f10i1•y..:.19^ OO 11,91125
TFROIIQ''MOTION F - RM117 10.000 -241 -WO
OR DD10+ FEZ' t O� �t1t3q-423�E?(2(9 `S�t�.'b0
Drt%J...0 EJt IMP.AC'� FEE 4-=� $1XIM
CFrl OF LA f :Ul'fiA
MUrn
PAIDN
UNS PIT, RES
$0.00
.4 AI'd�k81:I• '9Cc�9dV.9A:0�.,1i' ,S:r .er!'L',.IS�.b'1 L+'X7
54.,146 . �Qf
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
,r). x�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS /
Set Backs /�`—1/— C��- ��v
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
L
Ducts
Return Air .
Slab Grade Z�d Z �_s
Steel
Combustion Air
Roof Deck
r _
Exhaust Fans
O.K. to Wrap
_fid , d
�-
F.A.U.
Framing
I IF2�'_
Compressor
Insulation
vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines.
Party Wall Firewall
Exterior Lathe
Drywall -Int. Lath
6 /3
/
rk
Final
Final
_
�� p /Lr �(�
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
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�2_ OZ
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
r Sewer Connection
��7J�—iG—
Pool Cover
Encapsulation
Gas Piping
Gas Test/
_ p
Appliances
Final
COMMENTS:
Final j
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole r
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) ,