0102-066 (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 k Lic. Class Exp. Date
714.1 1 Q/3112,(
Date 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:
Cartier Policy No.
($04DUOLE. INS, XWC ,944648.0?
(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. �-
Dated j f, Applicant w< e ...•,� i -c a
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 is 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 x
the above-mentioned property for inspection purposes.
Signature (Owner/Agent/ Y1• �, '., G Date�g 7h i %r•
BUILDING PERMIT PERMT# '
DATE VALUATION LOT 01021066 TRACT
27519
JOB SITE
APN
ADDRESS 79 -WW 9 i%� d
tZ�►l- � t
OWNER
CONTRACTOR/DESIGNER/EN INEER
Cl IQTUiRY CRO ML CO:i14ML1A&S.US
C✓arr1: RY C",EtOWEI1.1 C''Cl:Mtdl4Jlv:UTO
153550, R.D0 ,T.rR Lq,1WR 4200
1535 210. T" bU°R.'Wi , @, IE 01201
SAX BE'lY.l.+lt RDWO CIA 92408
SAW BERYWWi< O CA. 92AOR .
(909)351.0+007 MU 2180 •'
USE OF PERMIT
R.Sr`I. DML MdODEL
CONVERT 134 SP OF MkRfdt" E SPACE E TO LAVINO ARRA failRINO INITIAL,
CONOTRUC ION Qin i10ML. At3DiTIOP1AL TO SFD PERMIT 0013-
BONUS ROOM 1:14.09 SF
PLAN CHECK FEE 101-000-439-:3133
CONSTRUCTION FZF. 101-000-418-000 $?8.09
w'1'iLONG MOTION FEY • R&.SM 101-000-•2,41-c000IN
et
COMM17C1ION .SND YUI (11111MIC IC
$1 "f� 1.?31.
1M.9 PM -PAD nW
RECEIPT
DATE %
BY
DATE FINALED
INSPECTOR
�^
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs J
Forms & Footings!
3(� G�J�
3��
Underground Ducts
Ducts
Slab Grade I
3 cop`
Return Air
Steel !
Roof Deck !
O.K. to Wrap
Framing_d7
Insulation
ICO ���_ �•
_
_AGK
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath J
Drywall -Int. Lath 1
6.tL "LO SlirnPa2 uvte-ar, +{ �� Ca' c��'�
I
Final] �
BLOCKWALL APAPROVALS
Final
POOLS - SPAS
steel
Set Backs )
Electric Bond
Footings I
Main Drain
Bond Beam
Approval to Cover
i
Equipment Location
1
Underground Electric
I
Underground Plbg. Test
Final i
Gas Piping
PLUMBING APPROVALS
J
Waste Lines I %Z^�iy p% ��
Water Piping I
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
l_ _ _ _
/
Pool Cover
Encapsulation
Gas Piping
Gas Test J
�/
Appliances !
�i—
f
Final
COMMENTS:
I
Final
Utility Notice (Gas)
p ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voftage Wiring
Fixtures I
Main Service I
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors!
Temp. Use of Power
1
1 _ _
Final
Utility Notice (Perm)