0111-222 (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 # q� } Lic. Class Exp. Date
7.
Date { ,°-r '. `* Signature of Contra o. .
///
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:
( ) 1, 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'
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 S Policy No.
w#'Bs°1 rsF3ND
(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 amploy 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�,wor�kers' compensation provisions,of Section 3700 of the Labor
Code, I shall•forthwith complywith those provisions. Mr
Date: e, f— %� Applicant Iy�' .
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.
•x.. a
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 tfi�is City to enter;u.pon
the above-mentioned property for iA ep ctio_mp`Urposes. � 4�
Signature (Owner/Agent) �"... r^�ti Date'"' C� r
3
BUILDING PERMIT PERMIT#
Jf
DATE VALUATION LOT TRACT
I 29457.2
JOB SITE
APN ,
ADDRESS 49�-2.19) RAITC110 PG.i TE
649 -IM -W?
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
Mc
oil
PO B' OX 1716
79-295 RAWHO UN IQUMI A Det,
1.,,0.QLUNTxA. CA 92253
]:,.A.Q`"T.A CA 9225:3
(760Y1711941 CBI -41 2996
USE OF PERMIT
S -1.107, *5511L.t5.'A5m7,f?. F'1~R.f' 1T D01Y.3140T tt+fCLUDIF L WCK WJ~'al.:A .,
P0011 VA. Oil DRI'' YWAAY APPROACH ,
Z
V• R.
t; ORC'pOP.8 .T30 527,ao SF
0ARAC2MA1tC'^AT
MA'1ATED COLST OF COMM ON
351111386M
;'OMI TAUCTION FI 301.000-438-000 $);plm
PLAN C:Pllib: K" FES Mts.•73
LRUA 'diik:�ix, � 1t1.i»C�1C3�d2Ct Ittr0a0 $2 46.71
RWW!'91a'J0 ME 103 -000-419-000 $205.00
S"f`12.C9NO h10T1,0N 'EV;'R - RV5.1r) 1011% _000441-000 $35.14
ORADINO FEE 101-000-423o000 $20,?944
1I.MVE'LC, MR IMPACT YRZ $$1,907.00
.lb;i?T rN PUBLIC PI..4�i;�'.8 • V1,111270.001')-44 270-0010-445-000 S3
RYq_'r`O ITcL3.r iY%?�7 L'IC.°��
���:t,� L-1= �y��i.� P.AJD IMES11
Via,"3St.?�
° FEIM i1 ITEN DUE NOW
$4"mos
Tm
RECEIPT
DATE
BY
DATE FINALE
INS R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
y- I- Z
POOLS - SPAS
Forms & Footings
Exhaust Fans
Slab Grade
F.A.U.
steel
Steel
Vents
Roof Deck
Grills
_
O.K. to Wrap
Main Drain
Bond Beam
Framing
Approval to Cover
Insulation
Fireplace P.L.
Fireplace T.O.
Underground Electric
Party Wall Insulation
Underground Pibg. Test
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
'
Gas Piping
PLUMBING
APPROVALS
OPERATION
DATE
INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
POOLS - SPAS
Combustion Air
Exhaust Fans
F.A.U.
steel
Compressor
Vents
Electric Bond
Grills
_
Fans & Controls
Main Drain
Final
COMMENTS:
Utility Notice (Gas) I - y I `j__
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures _
Main Service
Sub Panels
Exterior Receptacles
G.F.I. _
Smoke Detectors
Temp. Use of Power
Final / -
Utility Notice (Perm). jZ - L ,
Final
Final 17�//—
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
_
_
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Waste Lines
_I _ O2
Electric Final
Heater Final
Water Piping
_ _
_
`�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_� _ t]'L
Encapsulation
Gas Piping
Gas Test
Lel /% - i9�
Final
COMMENTS:
Utility Notice (Gas) I - y I `j__
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures _
Main Service
Sub Panels
Exterior Receptacles
G.F.I. _
Smoke Detectors
Temp. Use of Power
Final / -
Utility Notice (Perm). jZ - L ,