0011-192 (SFD)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
,# (♦ Lid. Class Exp. Date 1/2(
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 A Professionals
Code). ., s
O 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,.
(f)' 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.
001,M) A, OLE INS, . t4YdC'.-!i9�G6J�d2 .
(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. • e `
Date:" i�'� 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 tabor 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 restriction's '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,supiect 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)+-s�1'f=.� s Date' �+Y
BUILDING" PERMIT" . PERMIT#
DATE VALUATION LOT, 0011-4:92— TRACT
3
tl /2 6 27i 19
JOB SITE
ADDRESS
APN
79-419 PeA. W.0 IDEL TWY -
^061-01W
OWNER
CONTRACTOR? DESIGNER / ENGINEER
4":T 3'!'iii Y CPC3'M`s7 4' wZiMMUINU1: S
Cw7`uRy [„'KOWF-LL CoYvfmC31i i:i:m
SAU DERA1AR1;WO CA, 92408
S AI:`Y BERMIRMTO CA 92408
2120.
I ISF OF PFRMIT
3F0 u LOT S PIAN 2RJB URN! 17 S OUS NOT Itdt,WfiEBl°. C a
WA,TA.d%°001JAPPR.W�CH DR.Tt,l?WAY
TRACT CONSTRUCTION tgS9A,OD SF
POi7,Ci•U.P.A.TIO 36.0 SF
MRAODCARpORT (M
MOF CONISMUMON'
CONOTRUCTION F99 lf)P000418.000
PI.KN CHECK FZX 101-0004.39.318 IM24.33
1 ECHA ICAL FEE $000.
2Ci.l�t;7 li ICaA1 6?a1� : 101 $94.40
1�i.Lr iAic APR 101 *0000419.000 $122.75
STRONG MOTION iE.td a FG,F IV 10)..-000-241-000 w".23it
CRAD]ING PER
r)FVH1,t7iP?Jt: IMPACT
ZUB-°I(YrAl C'C9k+3'Ei'.I:h'.i. ,1J.ON Ad`7i1 PIAN ME
L1 ` s M-PAYD PSM
$0.00
v
' , .._:A WJ'°ELi±.i a .[.-..f'.�14�`r., �.:L'YP.. r•.i� 9.J 4.'+�r. tS a.S tl{r
61,29.3,49 -
RECEIPT
DATE�.
BY 1
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z�.ary _
Underground Ducts
Forms & Footings
Z �_pr�
Ducts
Slab Grade
V,
Return Air
Steel
Combustion Air
Roof Deck
2 Fd�
Exhaust Fans
O.K. to Wrap
' w ���
F.A.U.
Framing�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
3
r—o''r plr�s
(_1_9_lar c�
Final S L3_d/ 6C
BLOCKWAIAL A APROVALS
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 Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans .
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
' ]�-
Appliances
Final
COMMENTS:
Final$3
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
-Low Voltage Wiring
Fixturesoe
_
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power ��l
Final
Utility Notice (Perm)