0102-060 (RER)LICENSED CONTRACTOR DECLARATION
I hereby;giffirm 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
Date 1 +"'tet. Signature of Contractor^
OWNER -BUILDER DECLARATION
I hereby affirm under panalty 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:
Carrier Policy No.
(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: --3 �,_.- �.r,� Applicant
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. ,y
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/Agent) j \N. t_;', ; d q l Date:.. 11 : >Aw
-
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (3.EYr?- �"]]� TRACT
xlwk0m 58
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MINWRY RY CROWE LL CO C[F.t'�1 PSO
t:':i:�fi IRY MOWELL M"XkM. TFS
153580,,°Lnjkl?', nx kno
1535 30,'D*3MM E, 3 "(10
0.1AVmys19noXLINp`A PUN,
JCYBLtA167YNO r '924 08
(905))381..60('7 04U.4 31210
USE OF PERMIT
CONVERT 134 3F OF OARAOF, SPACETO LPJ'MCf eARFA 1:)ii1@,171 O 1N1TLRL
CONSTRUCTION OF ROM ADDITIONAL TO 31D PEWIT 0008-191
lAONU WOM 134,00 9F
ES'I",81 Ix1) COW 01r CONS"1Uf lCMON
PLAN CHIRCK RE 101.0000439•,316 1146.80
C:0W,W1?UCT1Cf.Q 1K.1d; 101-000-418-000 M.60
WMITRICIAL. M 101-000-420-000 $101
►'1'd;:�1Nt3MOTION WE - d",.i.,)11.) 101.000-211-000 $'50
A
tY
Slit -T°alAL Ca2ay'r€tTial Tom Am 1)1 kg C&IFXx
$121.31
1+.1��`��C1'�'yRE-P.f ID 1 7,21
$0.00
- a 1.49dAl, JCS'iA4AVS�+.,C..f d'S"`a1Yrll MEN
a' aLA
RECEIPT
DATEBY
r• I' 1� ~;rt
y
DATE FINALED
INSPECTOR
'a, s.
a
INSPECTION RECORD
pw
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING 'APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 1 3[
C6 f }-
Return Air
Steel t
Combustion Air
Roof Deck I L�/(p
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing l 1p,
Compressor
Insulation I �jl
Vents
Fireplace P.L. I
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath I
Drywall - Int. Lath 1
]
Final
Final
POOLS - SPAS
BLOCKWAI_ APPROVALS
steel
Set Backs
Electric Bond
Footings I
Main Drain
Bond Beam I
Approval to Cover
1
Equipment Location
i
Underground Electric
I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines !I Z( fp
C�'G
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I -
Sewer Lateral I
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping 1
Gas Test
Appliances 1
1
Final
COMMENTS:
Final"
Utility Notice
Ffl�
-
(Gas)" -
ELECTRICA APPROVALS
,
Temp. Power Pole
Underground Conduit
Rough Wiring I
Law Voltage Wiring
Fixtures
Main Service I
Sub Panels I
Exterior Receptacles
G.F.I.
Smoke Detectors 1
Temp. Use of Power
I
Final
Utility Notice (Perm)
i