0102-064 (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
PF 'onals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date--" '< ! Si nature 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 Sianature 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.
GOLDEN RAMA— INS, AFWC.-544068-02
(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: j Applicant` >. } , ✓
_7 11 ,' if a iia y. .,L', •►W -'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 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 he
upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date._L;/J '
BUILDING PERMIT PERMTN
DATE VALUATION LOT 0102.064 TRACT
49.80 1.2 27Ss9,
JOB SITE
APN
ADDRESS Thy �qy y / ��7�, y�aq l
7.�"'•?�"'tt9 �i�'e�49:Y. Q AiAb�l.d .2Z.F�'�.�i-
�p
rFfi 'I a -f.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
C:` IN'WRY CIRCIW.I UL CIDDIWLi 'Ilyz
C.`W110 OY CROW L, C:IONOW,-147M
1535 30. -D' UIRE °i, 0111. IWO
1535 SO. IV ETAM7a UIT. 42.00
SAW 1'- oFF.la'A42D.iNO Com. 92409
0IRAU EMWAPIM140 CA 92AOS
(9095)381.6007 r MA4 2120
USE OF PERMIT
R&MINTW:
C:f;7Ai'U'-wr 13+5 Sr' Ott riARAar, Smar To LIYF'tNC4AI' AMA I.3i RlNlt3 rNinAi.
COA1fiI'j'PAXTION Of? 130M.rfiad7M fOA A1, TO 3FD PERMIT 0011.201
BONUS ROOM, 134.011) 3F
i�i67.'W COWrO CC?,�i°.r'71��&�C�`.1I�Qk.4�'
4,649.S0
q� p g spy �p ,y ,Q (EKST
}� WIT
pdL�a.7YA,I.J6 Y'fP&4F aY V LPI�i.'/.ARd Y
PLAN CHICK CK FEE i tDl-WO.439-31 8 $46,80
Cb?7NSTR.ZJL:7IDN �� 101-000.418-000 frnso
ELECTRICAL, FEE 101-000-420.000 52101
.
80 -9 -TOTAL OY.` L CVWURU 1.5.:.01 AND PLAN CIDE"
1Y XrM, FE'RhUr FTM; DUE NOW
2-1
X1
RECEIPT
DATE , / % °BY
!1�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs /L
Forms & Footings
z I
Z�
,
Underground Ducts
Ducts
_
Slab Grade 3� +s
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap ��_
Exhaust Fans
F.A.U.
Framing . _ l
Insulation —Q/
Fireplace P.L.
Fireplace T.O.
�'
Compressor
Compressor
Vents
Grills
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall —/
Exterior Lath /�O��
Drywall -Int. Lath !Or/
Final rl—
BLOCKWALL A PROVALS
Final
POOLS-SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines12, �y ��Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans /
Sewer Lateral t_ �� �.�C
O.K. for Finish Plaster
Pool Cover
Encapsulation
Sewer Connection C9
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final ��Q.la /J� ✓
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final!
Utility Notice (Perm) �-�"✓