9808-049 (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 # Lic. Class Exp. Dale
aIRS234 B 12Js1/9k.J
Vate �/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 -e B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under.penalty�perjury one of -the following declarations:
O 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.
(%4 1 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.
PERMIT # CONTROL #
n
% , BUILDING PERMIT _..
DATE /�`9� VALUATIONS, q� •I 3.1%0 LOT TRACT
��.
JOB SITE
ADDRESS L1�!-b0l b4+A✓I,I�fl~If. coeJRT
OWNER CONTRACTOR/DESIGNER/ENGINEER
fit' f.`w�l i..L �C.�V�1.7$'. 3LO�.+t'i� n?iVl.:{...2.�X:.l's.C3E`�`1f� R&.1 SSOC..
15 ei l i�.F�l'i.E is
786 i S NAPL ES DRIV.E,
LA til 411',7A CA 9425-1 � , 4 QWNTA CA 92253
(() 172,-0222 CB.114 3 458
USE OF PERMIT
SING
S L.P. FAMILY DWELLNG
a.FI3, PLAN sA'R LOT i:31; PERA411. DOR5 Nar I CLITL E BLOCK '
W ALLS ORP- 0L. PLAly L;1.1.EC..IC. FEE R UC'!sf) 25"•o FOR A.R.-U TIPLF."ISSUS-1408 Or,
f
TRACT C0 S-r'.i UCr10i4 2 f)25.i3i3 sr,
'€'or.,C:l"Wrio 52.40 3r.
frARd UCYCARPGI;ISV 439,00 %W
:fs'6 �%f. +✓.1�i� C l �7
lix"A` ATE, D COST .01f 't.OTNIV.RU ION
(This section need not be completed if the permit valuation is for $100.00 or less).
RMIT EE SUid'lAIAWY
( ) I certify that in the performance of the work for which this permit is issued,
CONS`I'i4tK: 1.10N FF.F. 1.01-0004 19-060 �a709sV
I shall not`employ any person in any manner so as to become subject to the
PLA14OfWX. •~ Mm 101-000-4,39v318
workers' compensation laws of California, and agree that if I should become
MJ HANICA.� FIX 10 1 %jai?_ 62i�015
subject to the workers' compensation provisions of Section 3700 of the Labor
: %f✓&E[UCAL mak, a¢ -i 3=4�ao o Si28.i4
Code, I shall forthwith comply with those provisions.
✓bate: FLIM? •Applicant t-af%r R .:-: aJ, I f,� •'
'
.P1xgVJBfNoFEF, I{)WW-419.000 $140,7514T
OOG-
FETI, 10,31D .1014 241 -000
Warning: Failure to secure Workers' Compensation coverage is unlawful and
CRALANG FEE A101-1)0),423.000 V-0.00
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
iR?t`RA,ST9, CTUi2EVU7 225 -CO -443-M2 32,6167;64.
of the Labor Code, interest and attorney's fees..
m.T IN PU161JC f,9' AC;FB .,RE10 701-M-255-000 gi4f;,13 .
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
SUB =T M` L r%C�S:a'�L�•1�'1"1,(�.� '�-i)ilJ �jA)1i CHECK
k
& hold harmless the City of La Quinta, its officers, agents and employees.
LESS fli-E-FIAM FAT'S
$'0.00
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
COTAi. PC�i�l� ��'�S DUE, NOW
�'�2C'''�
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.
`/ �Q
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
., gnature (Owner/Agent) t��d= 7'-1>. tr �, d-Alff ' afe
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
!m /p�
/ 6 `d
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Q
F.A.U.
Framing
6
Compressor .
Insulation
3 ��
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
0/77
Final
Final _
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
T
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
f �2 _ q,F
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
Final
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
O iiity Notice (Perm) 7�
COMMENTS: