0102-055 (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
Date!.if t-+ 1% Signature of Contractor
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:
Carrier Policy No.
00LDM M01A INS, NW -3i 40159-02
(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:`l Ji Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each persop. at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. L
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws re ating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) j_Lf ,Date•R' j ' 4� �' •' 1
' BUILDING PERMIT PERMiT#
DATE VALUATION LOT; 0 �^a .7 TRACT
4
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
MW aTT :r? CROW M 1... COMMtN3°i 09
O_Ew my CROWE..L EuokaituqiTl a -
1:x.+5 so, OD -1 ZJRMET, ME Iigoo
1535 301 Nom, VI~r, *x'.11'' #200 `., ,
SAS XARWA%tCiWO CA 91.1108
SAN : F"ARD IO CA 92408.
(909)381.6007 MO 2120
USE OF PERMIT
CONVERT IM SF 07 C,r}MA09 SPACE TO i.iVINO ARFA OURINQ INITIA.t., ,
CONOTRtjCTION OF .tfiONIF. ADIDIT:10HAG ` 0 8FD P19"rl T 9013-196
BONUS ROOM •• 134.00 OF
,
E.ITI�: , (.°C?bT 0117,:i',"3.NI1 v�•Y$TFION
4,649J30
P1.01 0111 6 X RX? 101-000-439-318 IG.t
CONSTRUCTION 14MR 101-000-41.8-000 .00
F.IXt';TfUCAI, FBI 101x000420-000
SI'k ONO ?dCYf►r, N ITITE 0 2,E ID 101-000"241-000
cA p
SUB -TOTAL, C0 , RUC-ff N AND PLAK Crk17E:C'1r
LESS }'RR -=All) FM
$0100
MAL PMWf PMS DIDE NOW
$121-31n
RECEIPT
DATE' t
By'\;
DATE FINALED
INSPECTOR
�ir t ..,
._
�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade !
Return Air
Steel 1
�� 7 . 4��
Combustion Air '
Roof Deck
Exhaust Fans
O.K. to Wrap ICI
F.A.U.. • • ,
Framing !.
Insulation I
_�_
3— moo 0.1
Compressor
Vents
Fireplace P.L. '
r
Grills•
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall;
Exterior Lath 1
Drywall - Int. Lath i
`p
I
Final
_
Final 1 ./�� ems/ is
POOLS -'SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings i
Main Drain
Bond Beam i
Approval to Cover
1
Equipment Location
Underground Electric
►
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans t
O.K. for Finish Plaster
Sewer Lateral .
ool Cover
Sewer Connection I
.,`-
Encapsulation
Gas Piping I
Gas Test
Appliances ]
(((
Final
I
COMMENTS:
I
Final
_
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole(
Underground Conduft
Rough Wiring f
Low Voltage Wiring
.Fixtures 1
Main Service i
Sub Panels 1
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)