0111-219 (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
� .
Datefir ,*'%� !�r' l Signature of Contractor ,j p
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'
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:
Cartier
. lTAT dILSD Policy No. 041 6 'V511
MA
(This section need not be completed if the permit valuatiori 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' compensatiow-provisions of Section 3,00 of the Labor
Code, I shallf orthwith comply with4ose provisions.,
Date: ,t'.�� ,F / Applicant P J
Warning: Failure to secure Workers' Compensation coverallge-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. d,
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 authorize representatives of this City to enter, upon i
the above-mentioned property. -for inspectioN!purposes(ts
Signature (Owner/Agent) ( _Date 1
BUILDING PERMIT FERMT#
DATE VALUATION LOT 011 TRACT
29457.2
JOB SITE APN
ADDRESS gg Nt cry g3 y y '&0-10"0
04 t yr.
OWNER CONTRACTOR/DESIGNER/EN INEER
4
D D..FA U DSIVEMPWwa WARKS (19O33S".CRUCrIr.O
POWEX 17 TO 79-29S.RMIC7,10 LA Q�MUA DR,
LAq..101iA CA 92255- LA QtT1.Z!l'tiA. . CA 92253
C/60Yl71 F a'.41 CBS 2996
USE OF PERMIT
11
SV1J t" i1 '?i.AN M:392i;S: ,PERMITfi?C ESQ '+ OT IINCLME
WAL-1.4, P4,504 9PA OR )3IUVWA Y APPROACH
t;l:STOM CC?ht'ST%.i CT110I(
4,3, .MOD Sig
POR.CXffT".f1 IO
552.00 9;F
0�,1(�Fa(�!T4`L.�4k PCl3�
71%)-00 By
CONSTRUCTION DUE
101-000-418-000
$1,5460
PLAN CrWKFM
101-000-439-31#8
$512.01
WCIANRRWL VEr
103-000-421 000
$136.50
1±;.LEC9'ltlt AL,:I FFI
$IM'•{?0(}-•420-000
$22§tM
PLU"MSTWO M
101-000-419-000
W&25
SRCYJsM MOTION FES - RESID
.10.1-2510-41 �DDO
$:3143
° . i35`�aKr i
1 f3 i 4t�i7{J-423-Wo
. 20,00
I•}plyr,f OP41i IPAP.M.T ME
$I,�ifb3.OfJ
, ,RT R4 PUBLIC FIACES !illi: 2704W -445x000
• 'a
0111XIM.-UMON, 'AM PLAN CIVIC -M
°' j 2®�� �T,L PUMAT V107S VUR: Now
RECEIPT DATE .� BY A, DATE FINALED
INSPECTORff
C1°
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
,BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs ] {
—/O —r— _04-1Underground
Ducts
Forms & Footings I f
Ducts
Return Air
7
Slab Grade 1 f �� — /�' _
Steel
Combustion Air
Roof Deck 1(
s / 7 _
Exhaust Fans
OX to Wrap I I
O�
F.A.U.
Framing 1 {
Insulation
cS—j Z
Compressor
Vents
_
Fireplace P.L. If
Z,
Grills
Fireplace T.O. I I
Fans 8 Controls
Party Wall insulation
_
Condensate Lines
Party Wall Firewall II
Exterior Lath
Drywall -Int. Lath
I I
Final It
/� N ' �,
Final
Z—
/z - y— S
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs 11
FootingsJ `
_
Electric Bond
Main Drain
Bond Beam
3, — Z
Approval to Cover
I I
Equipment Location
1(
Underground Electric
i 3
Final
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
f ,
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping i y
Plumbing Top Out 1 S���
Shower Pans i 1
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral ; l
_
Pool Cover
Sewer Connection I f
Encapsulation
Gas Piping ) y
Gas Test
Appliances I f
11
Final
i1
COMMENTS:
!t
if
Final
Utility Notice (Gas)
ELECTRICAL' APPROVALS
11
Temp. Power Pole 1 f
Underground Condue
Rough Wiring
Low Voltage Wiring
Fixtures I f
Main Service
Sub Panels
Exterior Receptacles 1
G.F.I. 11
Smoke Detectors 1 y
Temp. Use of Power,;
I I
11
Final
Utility Notice (Perm) I y