0210-023 (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. Date
674. 7
4 'B .'Me ,+ �' j
'6- a
Date `''''' Signature of Contractor --
i
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.
'()!) 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 STXYZ V(1141) Policy No. 046-tit,000773;10
(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.l°•should become
subject to the workers' compensation ,piovisions of Section 3700 of the Labor
Code, I shall forthwith comply with those pii``ovisions�
,,Era -ie: - t' Applicant_
C.
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',.
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemn
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information s
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for nspectio p rposes.�
! , j -..•/r
_.Signature (Owner/Agent)` Date- r �'
BUILDING PERMIT PERMIT# ;....:
DATE VALUATIONs?
momoo20 LOT TRACT ,
JOB SITE
ADDRESS 719-• , 11AN .0.Jai�'QUtNT�L��R1VE
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD DIFF .f �F .OPWr
SIWMIS C011MIRIXI-XION
PO DOX 1716
79-:295 RANCHO LA QUJNT DX
LA.Qtl�rA. CA 92.213
1:.AQZ;t(XTA CA .922,53
(7 c�7'7 'i • 1 +�# I "F11 # 2996
USE OF PERMIT
�5E+rla • LOT 20 EWC:ANTO 1: PY-RI IT 0023 i NOT INCLUDE 01LOC K
WALL % P004 SPA Oft DRIVEWAY APP}SMAC H 75% PLAN CHECK PE
R.L?x1iJCTION FOR. MULTIPLE ISSUANCE OFaA.'f>vlF-PLAN TYPtr.
C11MM C ONST A1.iXTION ,6dF!(.Op SF
PORC H/PA`1'IO 267.00 SY
QA.RAMICARPORT 66.4.00 SF
XST04ATED CCPV OF C% 111,671WDM 'rIN
1�iL' TT Stit 901 gMway
CONSTRUCTION PEI: 101--000-08-000 $40611.00
PLAN CHECK ME 101-000-439-318 $2111.90
MECHANICAL HIM 101-000-421-0010 5105100
t):1 R TRIC.A L FEE i 01-00 20-000 $160..01
1101
PLUMD1100 H011 01.000.4141.0170 SM'aS
ST ONO MOTION ME, - REM 101-000-244-Cr00 $22.09
GitAT.1WO Fid 101-000-423-000 M.0
D x'13 ELOI'Vit 1%Vl'►'.&K'`7 FU e,�3(PS.Ott
ART IN PUBLIC PLACES - t UIC TI"00-445-000 445.000 $52,13
• I
;;E1 - CTfi,I. °CS TRUi'TiON AND PI..W £1
>21•.38
7,'0TAT, P MW 1r'Za;•P :1' DIM NOW
Mewl,'
OCT 3 v 2UU2
CITY OF LA QUINTA
`•. ": •.
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR Q
INSPECTION RECORD a®
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
— -3
Ducts
Slab Grade
-Z2
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
—,/1 —
F.A.U.
Framing
— 3
Compressor
Insulation
_ y-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulatic+n
Condensate Lines
Party Wall Firewall
Exterior Lath
— /_3
Drywall - Int. Lath
— —73
Final
Final - —
BOCKWALL APPROVALS
steel
POOLS - SPAS
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
7 7-7,
Heater Final
Water Piping
Plumbing Top Out
�j✓_�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
/�-,23 -.�
Encapsulation
Gas Test
Appliances
_
62
Final
Final _
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condrit
Rough Wiring z
Low Voltage Wiring
Fixtures
Main Service AI
Sub Panels _
Exterior Receptacles _
G.F.I.
Smoke Detectors
Temp. Use of Powe-
Final ,
Utility Notice (Perm)
COMMENTS: