0202-215 (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
`.'; 7C?1tib3 B,Mm, "—Ao, 1/31,10.3
Date��° Signature of Contractor �-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's.
License Law for the following reason:
O 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. 70.44, Business & Professionals Code):, - '
( ) 1,. -as owner of the property, am exclusively contracting" with licensed
contractors, to construct^ the project (Sec. 7044, Business. ,& Professionals
Code).
O I am exempt under Section B&P.0: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
Wdtion 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.
xAT& MAD 00031640813-391
(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 tho ,,� r6' ''d S.
Date: z �°:.;7 .Applic nt,4!"_.bsc
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth"-onthis
application.
1. Each person upon whose behalf this application is made & each„person of
whose request and for whose benefit work is performed under or pursuar(t.to
any permit issued as a result of this applicaton agrees to, & shall,iindemniN
& hold harmless the City of La Quinta, its officers, agents and employeesl'�
2. Any permit issued as a result of this application becomes null and voldlifl
.work is ,not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit tofcancellatlon�
I certify that I have read this application and state that the above;mformatlod Is
correct. I agree to comply with all City, and State laws relating to the bulldgng
construction, and hereby authorize representatives of this City to enter upon .
the above-mentioned property for I pection purposes. ti
/Signature (Owner/Agent) v%i Date �� y
BUILDING PERMIT PERMIT”
DATE 'VALUATION LOT, TRACT
%�
g
JOB✓SITE
APN
ADDRESS .
A 80 .T.ZANC.1r1':O LA 111 (M
64940"15
OWNER
CONTRACTOR / DESIGNER / EN INEER
i
' J�??Ny�p S�i�'h�rt��(fiW♦r�,1pM�}'.,i`�1{yr,�r�ll:.�e::}ae+Il
'b'�.d/�ll:';�fi�
�j) 'J 9/r
.Y �1���1't.L'..M1S.'.AP.S 0.✓'.LJ.��c4�./.t *aT�.fi' S.Y�
yy��Y':'jEj`u"'1'$�3:'^'Ts�'j£I+Js1:.PYf�r'Tl1C
Y��'�ii +ni'j'.{i.�.l..Y�i`11 air � ��
� M141=310 CA 92M
U QMWTA M 92253
(7610)7`11=3363 CWt 4972
USE OF PERMIT )
M1101,12 F,f?�tii& Y DWELIMIG
518 '> L,Ui k94, .t'L,A1d fC:. 1rL%&id9' C2C:)1F�i N4'?T 1"�1t�k,l�i'33� �b1...i3Gs°f
wA.Lt �Oiil♦�.51',f�OR l i �1 y.4tiP ?i.C?d".Cc ♦ 7$�Y91�1rF1N t"+j39?;t" PEE
RMtlCTION MR MULTIPL.fr ISSUANCE, OF SAME pWwiyfsn
` PI&CIF CONISTRUCTION .�172,00;9F
CARP,�01OXARPORT 643.00 8F
�:STRJA.IE:�:� CC?S';£' OF CC?��+,r9 D`��1�'�'�.. t:. N
1911926.20. "..
�''ii �jj 7�$��jj��]�� J�{{.ii.''� /
i•'A'JSQBVI' .4 aL� MINWAR
CONSTRUCTION PEE 10.1.000-118-000 8961,30
AL" CHECK WE 101-000-.439-318 8190.43
MECHA1:1CAL PES 101-000,421-000 892.311
r
Lp ECTRIC:AL,IP,?E 101-000-420-000 $1$7.33
PIAIMMO YEE 101.000-41.9.000 $191M. '
."r1' RONO %VYG.?Vi. W f"PIR - RESID 101-000-241-000 $15.19
MAD�.iliFEE 01.000423.000 S21 t10
IgEV4PER IMPACTME$3,4 oo
ks'CIAB .TGoTAL VO1 7'RUCYTOkTA!ND I. IA14* C",I3tE K.
$3,548.37
LESS P -PAM) JFF..39
$0100
�- � ��.�.-/II*,
� � 1Yyry♦y.,�•� g'y�,v� p.�g' nY` `ye'� y� Grp '�y
'' At � .. aK 4,JDCatG.i .¢ 516�SPE�S.:�`�' L+�.Lr�J.L. iY��
�, F��p F)
t11•.T6er9�ae$ d
-FEB 27 23
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4 -
RECEIPT ^' T
DATE{ f
BY,-,
D E FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z5
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade—
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_ I -� _ _
F.A.U.
Framing
Compressor
Insulation
_ _ _ _ _
Vents
Fireplace P.L.
_ _
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�✓
Final O- /—UZ S
Final—Ji/-oL
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Q '
Heater Final
Water Piping
Plumbing Top Out
_ _rip _
Plumbing Final
Equipment Enclosure
Shower Pans
U__
_
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
—��--
Encapsulation
Gas Piping
Gas Test
Q
Appliances
Final
COMMENTS:
Final
Utility Notice
��/`�% ���El_� LTE
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
L�
j
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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