0102-067 (RER)LICENSED CONTRACTOR DECLARATION
I hereby;afiirm 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 '-/ / ` 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 Jie 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.
OOLDM4 RACHA1NS, NWC-544068-132
(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:. -9 11 Applicant • 2-uLl
4g (
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, & shail, 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)�f�_l f "7� :f {' ? Date- j %I 1••1
BUILDING PERMIT PERMT#
DATE VALUATION LOT TRACT -
4' ' 9 S 67 27119
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
CE'l a"UR Y• C ROWELL COMMUNITIES
CE.N'Z"i R Y' C'3 OWre LL riOWNTC3NUX, r
1535 go, 1>0 i3l2ZLi C, IV& -0200
3.335 so, v. UARFF.�:u, ume, X200
StX :13•HR.1,TAIZDTN0 Cel 92408
W' F:' NA `DINO CA iWOR
(9179); 81-60m CT,'14 n a o
USE OF PERMIT
C;'UldVEXt 134 MF OF CfARAC E SPACE TO LIVING AREA DURINO 11141 TIM.,
CC)NamsG''PEom OF HOME A17DITIONALF TO 317D PERMIT 0011-203
BONUS R.001M 1;94.!70
EST,Ct1LKl['. D C O I' C3I! C031MIRIDe:,°17011
PkMMIT P SA Y
PIAN C10101. Mr, 101 -MO -439-316 $46.80
COSI aTRUCTIONT 1±tlg 101-000-418-000 $1.00
J&1AC T RICAL PIEZ 101-000-420-000 $101
STRM40 410TION FEE -1' ID 101-000-241-000 $.30
e
IMS PRE -:PAM IrME0
$0.00
T<YfA . PKRM-'I ' 1';!' tib- S DUE, NOW
A7 9
tibY
4
RECEIPT
DATEi
BYE
DATE FINALED
INSPECTOR
�.
Ki
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
_ _
Slab Grade
Return Air
Steel
Combustion Air
Roof Decky_� �O
Exhaust Fans
_
O.K. to Wrap
Framing ��Compressor
F.A.U.
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
�(Z'C.a
ty3�--/1—�-x�t��
Final ��le-
Final
POOLS - SPAS
BLOCKVVALIL APPROVALS
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 Linesf �'��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral _ J _
Pool Cover
Sewer Connection
Encapsulation
Gas Piping _
Gas Test
Appliances
Final
COMMENTS:
Final J
Utility Notice
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final`�_�
Utility Notice (Perm) ``