0111-228 (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 EXD. Date
Y
674974/ B HCC'
Date,/,j ^� plc'. Signature of Contracto
r ,/
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 A Professionals
Code).
() I am exempt under Section B&RC. 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
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 ST.A.TH FUND Policy No. 046-00V*38
(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 shallVforth4ith comply with those'sprovisionsr ),
Date.19• 9 >r Applicant
Warning: Failure to secure Workers, Compensation coVda-ge 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. 6, t
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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. „ +"
Signature (Owner/Agerit '�`� 1 Date i .11IIi
BUILDING PERMIT PERMIT# 40,
J
DATE f / VALUATION LOT 011J.•'2201 TRACT
JOB SITE -
APN
ADDRESS �QD».1 �FAv.AT�ar' .E� ���� }
649-100-4017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
.IPO B,'XX 1716
79-295 .ONC13O LP. QVWTAD ,
iAQL"1WIA CA, 92253
x.AQ1.MITA CA 92253
(760)771.1941 C'B14 2996
USE OF PERMIT
SP'O -LOT 61 VLA34 .MMP- PETM11T DOZw'NOT A2+iC1.,LfDE BLOCK WALIA
€004 SPA OR DRiVYWAY APPROACH .
CUSTOM WNST,RUCTION 4„243.00 3%°
PCaiitWlrATIO 522,0 V
r C@X0.O r.AC.-`ARPO1*T 710,00 Sly
ESTIMATE -0 C.:06rr Or, +C°ONbIRUCMON
351 -0
WASTRUCT10AFFE 101-000-08-000 T1,51*11..50
VL” CHEICK FV.9 109.000-439.118
hIRC;lir, 111CAi FIM 1131-000.421--000 $14fic5fi
rf-'L rf1tiCAL P&P 101 -OW -420-000 $246.71
P';WIMR1 0 PRE 101 -0010-41 P-000 $20,,5,00
STRM0 MOT1014 Pkv ° XIM5110 101 -I700 -24:j -000 $35.14
OV0 Wryf kZ I01 -000-4-a3-000 $110A0
!:?�6r'EL,OP1'R1?4PACT FE), $1,907.00
SXT13- &CATA016�03.':11ON'ANDPIAS C rX,
Tft r59.005
= IXESS PRE -PAID EVE113
$0,00
RECEIPT
DATE s.` -
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
C3 -
Underground Ducts
Forms& Footings
Ducts
Slab Grade
- (9- Z
Return Air C6
Steel
Z__
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
-% _ _
F.A.U.
Framing
�- - GZ
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
��_
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 Lin
Heater Final
Water Piping
rn
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
711
Pool Cover
Sewer Connection
/ — —Z.
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
6�,Z Z
Low Voltage Wiring!
-
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power.
Final
Utility Notice (Perm)
-Ij