9907-028 (SFD)N
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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 . Date
1.V 1a
4ate? / Signature of Contractb ✓l -' `y
OWNER -BUILDER DELL R ION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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 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.
(p 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:
STA"" 1".fiaa-+ 04,40 )73-N
(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 Califprmik, and agree that-sh Id become
subject to e w rkers' compensation prooVsions of Sedibn 3700 o the Labor
Code II f 44th comply withIthose p ovls+ons
�D te: Applicants
arning: 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, & 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 voidcif,
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.
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 here"uthorize rep atives of this City to enter upon
the above mentioned property for inspection urpo.
/Signature (Owner/Agent)-'` / il")+ Dates
PERMIT #
BUILDING PERMIT
1)*11,..91111
S + I
DATE VALUATION $260.911710 LOT (48 TRACTJOB
1 �^
SITE
APN
ADDRE S 79-1 11 CASA V11DA II A..RC0,E
07
(W-7-21.0.007
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'T'(? ;:)ESl:T.T PARV1?1..OPINAIENT
;;T'Ai'.KS CD 41 v' f'f;! 1CM. t_—)
PO BOX i7i6
7+I-295 FUCN640 LA QlAN T A DR.
LA QUI Vrik t�'A 92253
IA t: )IATA CA 41.253
(760Y1 71-1941 C.ftr,f( 2()%)(
USE OF PERMIT
41ati(;AX FAMILY IJ1NliL(..jKC,
tiVi3 PLAN MIR - PFAily IT 001k',_Y h;� r T INc:i UDL.i3a.00K WALL
`�R t'+itJi.., :1�'3u I+I,Afr.t.'Itf:;<;i{. fl'T:- ttl:;i)u�.; I'f6)N H'i l{i.AAl.li.!"1'Yi✓t,l',
118311ANCV. OR ;tNME C -IL 141l'i'tr.
+vtiSTOiLf3,K4.0 V
POR' 'Iili?A, F10 `?301.£1(1 .;F
GARrVIIWC"AR "47. 0'
r!a'�'A f ED COS ,Jif .liiUC T 1,:044 i
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+� C�Nf'ti'l`,(1�:.TIC:+ia1 f:I31 A t0l-II(3L►-4lk-Ui)i► a i:. �O,+.Ut+
N1,Aty f..'{if�C Ty ► Pf }()1-1311-4iR••�IR ^A7,f1^
h(I;t .'fAMCAL 1-1� 101-000-421-000
ELBLIRICAi, FEE 10-(?Utl 420-000
PLUMtkiNG VEE
STRONG n t _ TION 144_.1: - YK!,10 101-11f{{1-74 f 4M $2{;.f1)
GRADIa4, FE.E t01 -WG -4''.3+-00" :V'20.W
4 14Yto S'ii2U(rt'URE FE 215-000-443-3-16 $5,07.011
ART I PUFt AC k'd.AC S - RESIt 74401010H -•755-04400 (Y.. 111)
S! 034'C)TAi, CION,"UR!-K'i` ON n1Nf"{{)Pl.. AN '►-if ICK
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RECEIPT
DATE
BYDATE
FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_ 0-7— &L&
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_G{f
F.A.U.
Framing
CXJ
Compressor
Insulation
Gf✓
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Z7
Drywall - Int. Lath
Final
Final
W t<—
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final cd
_ 46/
Utility Notice (Gas)7.2-7-46/-
ELECTRICAL
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 C<)
Utility Notice (Perm)