0102-056 (RER)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
7141zt t B 1k '1Jt t
Date? rl�?. �T Signature of Contractor "''r� t -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 & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date _ Sionature 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 Policy No.
C)CeX AOU, INS. 3+3 r'd�• �iJ� -�
(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 those provisions.
Date: f Applicant --"•:-,.w-1 ! i"%
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 !his 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 wit 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.
i i ➢1
Signature (Owner/Agent) Wit' pj !` .f �../' l !' �'.:; Date'_
BUILDING PERMIT PERMIT"
DATE VALUATION LOT TRACT '
�d ,�9.&3�i3 18 2,11 5 l 4:
JOB SITE
APN
ADDRESS
01
79-.289 PA..' 1?1 1 Y
si dlasl '
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C:E1;9'L'CiRY CRk0W CL CCiA!tMUNA:1F'S
CDn''URY CSC?i1(ik: it COt+ MUN3s't..n
1535 1001 31), 3TY27111 MT, 000
1535 20T"EMM-l', 3TLe. #200
'
SAN I3.1i.Ri'3ARDINO CA 92408
SAMBl°.,1dNARIDBTO CA 92 408
(909).461-6007 Cr'DIA 4120
USE OF PERMIT
�3"'nrmi -I'AL 1d.Emomn,
COTNV&PT 1.0 SP Oil 0A.RiC19 SP6`aCE TO 1,1111_N0 ARRA fJUR.CN 0INI TIAL
C014TRUCTION OF.H O,tVR..f DDITfORAL O SVED PERMIT W63 -IV
.Ff('0plus ROOM 134.00 SF
:€f3M'tJX( CD COis':i' OF CONS1217tCMOR
4k49Z0 .
1'ILITTZN i'"Irk. K1UKARY
PLAN CH_F4K FEB 103.000,439-318 �a6.40
CUNSTIZUCTdi'N FEE 101-000.418-000 6e
FlECTRICAL FRE 11"11-M. Q-•420.000 $2,01
STRONG MO'd'1014 VM, RE.SID 1.01-000-24.1-000 ;S.50
4
SUB .1170 'AL C'0W.1'.€�UCr10 >7 A2T.D P AK CHECK
21.-i 1
rift,
TUTAL 11 t AH IPYES V01. NOW
1
J
RECEIPT
DATE ;113
r,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
7-.,. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i Z�
Underground Ducts
Fe,rms & Footings I
Slab Grade�
_
Ducts
Return Air
Steel
Combustion Air
P, -)of Deck (�
C �'L
Exhaust Fans
O.K. to Wrap i 'L�
e�
F.A.U.
Framing 5'��
_ _
Compressor
Insulation 1 d
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. i
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I _
Exterior Lath )
Drywall - Int. Lath t
�-
1 _
Final
Final
POOLS SPAS
BLOCKWALL i�PPROVALS
steel
Set Backs I
Electric Bond
Footings I
Main Drain
Bond Beam 1
Approval to Cover
!
Equipment Location
#
Underground Electric
1
Underground Plbg. Test
Final 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i
Heater Final
Water Piping l
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral I Z�l
Pool Cover
Sewer Connection !
Encapsulation
Gas Piping 1 Z
Gas Test
Appliances !
Final
1
I
COMMENTS:
1 _
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Polel
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service I
Sub Panels I
Exterior Receptacles
G.F.I. i
Smoke Detectors I
Temp. Use of Power
1
i ,
Final 17
Utility Notice (Perm).�-