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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
ly" / 071'31JO!
.7 7 Signature of Contra
Date 11,e Ael" 0
J-4 �1 - i cto
OWNER -BUILDER D�C f;l1A)TION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct"Ihe project (Sec. 7044, Business & Professionals
Code).
I am exempt under Section B&P.C. for this reason
Date of, Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations..
lh ave and will maintain a certificate of consent to self7insure for workers'
compensation, asr provided for by Section 3700 of the Labor Code, for the
performance of the work f ' or which this permit is issued.
00 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 carder & policy no. are:
Carrier Policy No.
(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, andMrt_h_at.)f I should become
subject to Pe rk ' compensation-K9yisid s of Sectio'n 3700 of the Labor
Code I fr� r,s . r!
1h !fth comply with-tfio�Wprovisions.
Applicant
D te:
u4'
VWarning: Failure to secure WorkLe—rsr-C-;mpensation coverage is unlavwvf 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 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 herebv autho resentatives of this City to enterypon
_ 'job, 76' .
the above-mentionle6r4ro foTrinsp , 10 es
�8/ignature (Owner/Agen D t
PERMIT #
BUILDING PERMIT
DAT!:�& VALUATION 5 LOT TRACT 280 1,2
1.3%8.30 65
JOB SIYE
APN
ADDRESS 7.4-110 CASA VIDA CJRC6,J'E
649-210-007
OWNER
CONTRACTOR / DESIGNER ENGINEER
1
T1.)
"A' - 1-0i I
9� ftKSC0NSVR.1J(1 "
P0 SO K i 7 i 6
79.295 ii;%NCHO LA WIiii-A DR.
LA. Qf iINTA CA �22_53
1_f� QuI.N-.r1.k C A. 92253
CB[.# 2!�KIJ5
USE OF PERMIT
.S1t,40JX'FA1v1Jf.A-' DWEILINO
SKJ - LOT 6S PLAN NO - PMMIT LXk,`S NOT INCLUDEBLOCK WALL
ISSUANCE OR SAME PLAN TYPE.
CON3TRUCTION 4,2421 (KA SF,
PORC01".K1,10
CYARAOEYCAIWORT 7 10. ($0 8F
F-STIA1441VITRIt'D MST OF C01111NISTRUCT2101114
PERNOT FIEU 'SUNIMA-11Y
CJ`)N&FKLK7FI0N FEE 10i4m-41840) IS 1, 52 1'. 9)
AfECHANI[CAL Ki 51)
E1XCTkJCAL FIX,, 10 1 -000-420-000 S "I., I (�, 7 1
P LUMUIN(-i FEE IM-OW-419AW S2105,0b
1101-000-423-000
225-W)44_'l,-3,il2
ART fN PUBLIC PLACV3 - IKESW 70 1
f(TVAL .0 SIRIK 1 AN
110), T) Pte i� N CH FCK
LESS P1-1C--PAI0.FEf:-'S
$000
7MA), PERMIT FF,&',S 01JE, NOW
sq'Itmos
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Food
OPERATION j
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
72`2177a.> ZWE
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
-y_- 2_7 cel—, dK�
F.A.U.
Framing
Compressor
Insulation
-7- Z 4X)
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
4�v�
Drywall - Int. Lath
cz,
Final I
Final
-7.2-a- ciu
POOLS -SPAS
BLOCKWALL
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 Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
AIM
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 7
ELECTRICAL APPROVALS
Timp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Urnp. Use of Power
Final
Ufirdy Notice (Perm)