0111-218 (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
�{
Date1 N }s r ° Signature of Contractor)
i OWNER -BUILDER DECLARATION 7
L '
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 owrier of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & 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 3T; -M, 1"k�HID Policy No. 046.007333
(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 Californir'artd agree that if I should become
'subject to thelworkers' compensation provisions of Section' 3700�of"t"he Labor
Code, I shal6orttiwith comply withAhose provisions.
Date-., , �fi- t` r�' Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100b6(Y,-ins
addition to the cost of compensation, damages as provided for in Section 3706 >
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on -his
application.
1. Each person upon whose behalf this application is made & each person of
whose request and for whose benefit work is performed under or pursuant to .
any permit issued as a result.of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La_ Quinta, its officers, agents and employees -
2. Any permit issued as a result of this. application becomes null andivoid if
work is not commenced within 180 days from date of issuance of suelr-
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above inform SI n is Q
correct. I agree to comply with all. City, and State laws relating to the t di g
construction, and hereby authorize representa'tiyes of this City to ente up,
the above-mentioned pr�perly.,f,r
inspection purposes. + c
Signature (0•wner/Agen) l p = "� Date /
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �$ �y'r TRACT
Z18,439W .51 2945 7 2
JOB SITE
APN
ADDRESS poIN7F649-1(n-007
OWNER
CONTRACTOR / DESIGNER /EN I(NEER
1.14 yGIC.'D 'M`�dfi
.
GARKS CWMt4C1A0p
r?") 33Oit 171 fa
79-295 RAN M-1.0 LA QUANTA IDI2.
LkQe.1 krlA. CA 92253
LA QU'.t IA (1A 92253
(16OXI-7 t -1941 4`131# 2996
USE OF PERMIT
=1 • LA)T 51 Plr9.$4 MDRM20. PI RRMIT C:(DMS'NOT rNCLUDE FIT, 'C:iC
VVALIA POOL, IWA OR DR71V WWf APPROACH
C0,03T M CONS'f RUCT1011 A804.0101 9F
PORMPr' T10 610.00 Sr
(1APAX)Ip-e`(A PCiR 714.0 VF
.G7+�D.�RdY.LL� .P.+. D 4�:CYS�.Y. +, 1F• S nYJ.A.l�NrArL'�J .3ON
31 `8�.0`4..�'�}..lM
y +��9�f ym�o a �5�
001417fRVCTI014 % 101at3t3���Ea s�000 $1, 40611
FLA11 C"H1�:4:;P(, 9M1tf at3lfa-�,'4 '_3 I,Iv0.9�i
M&C"HAN1,01ti., FEE 101-000-421,000 $ f ffi 1, vii
ftJ:(:TP11CA I., .PEE $207.42
Pi,1tiJMIAT +iO F10K 101-000»1419.000 9223.50
STR01.40 t* OT7.'ON FEZ • :4 0iD )(31-000-241--000
i(213 d3v0 i?l ? 101-000«423-0300 S%0.50
DLrkrE1K)PZr1 IMPACT VEX
ART W N&L.fC: PLACES -1C ESTE 270.000-445.000 szml4
M-1110TAL +Ctl9la11WI,TC: 2"f:(iM AND S' . ' C:' , Me,'
$5."416
11011AL PE3;F1+1:Lr2': F�F.�7''1' I= NOW
F
C 0 6 2001
OF: LAQ !d1 'fA
V 4
C7
�Ih. DATE . .A
:BY
DATE FINALED
INSPEJAQR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
01,11ep
Underground Ducts
Forms & Footings
41 —le- Z
Ducts
Slab Grade
Return Air
Steel
ombustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
(a - ' Q
F.A.U.
Framing
-20 - py
Compressor
Insulation
a� _
Vents
Fireplace P.L.
Fireplace T.O.
Grills
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final ��� ^ ��
BLOCKWALL APPROVALS
Final /
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
.S -,2y - Z
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Top Out
`�
Plumbing Final
Equipment Enclosure
Shower Pans
Sewer Lateral
_
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _?p o -2-
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) -?,-OZ