0003-120 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that lam licensed under provisions of
Chapter 9 (commencing with Section 700.0) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic.'Class Exp.. Date
743025 R r A 1.130/201
Date Signature of Contracto
•I VV. V
OWNER -BUILDER DECLARATIOtr
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 structureisnot intended or offered for
sale (Sec. 7044, Business & Professionals Code), . C _.
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 acertificate 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 thispermit is issued.
( ) I have and will maintain workers' compensation insurance -as required by
Section 3700 of the Labor Cocle,-for I the performance of the work for which this
permit is issued. My, workers' compensation insurance carrier & policy no. are:
.Carrier Policy No.
3144 flo 11 2 1
(This section need not be completed if. th6, peirmit valuation is for $100.00 or less).
(- ) I certify that in the performanceofthe 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 Califoryla, and agree that if I should become
subject to the 'workers' compensation pfovisions,of Section 3700 of the Labor
Code, I shall forthwith comply with thosy,provisiony
Date: Applicant—
V
Warning: Failure to secure Workers' Compen ' s tion 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
fora permit subject to _the conclitionsand restrictions set forth on his
application.
1. Each person, upon whose behalf thisi 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 hereby authori e representatives of this City to enter upon
the above-mentioned property f2inspection purposes.
Signature (Owner/Agent) Date
y
PERMIT#
BUILDING PERMIT
DATE VALUATION $331,520.80 Loic&3 .-TRACT .293,58-
JOB SITE
ADDRESS TSX495 ROYAL ST. GEC
OWNER
71B-080 CALLE ESFAW SIM.- 201
LA QUINTA J I CA- 92753
USE OF PERMIT
S1,1NULE.FAA41L.Y J_)WJ1_,1UNQ
APIN
CONTRACTOR / DESIGNER ENGINEER
78-080 CALLS ESTADO ?.71,5: 201
LAO CA 92253
.�ANTA . I
CRE,# 5407
aID-LOT6 P-Lius, iPr-R&OT DUES'NOT MCLUDE
BLOCKWIA11 OR, POOL.!
75Q/4 1.11,AN CB Ch K-1- f41!1)UCV0N Ot4 fVILICURLE ISSUANCE
OF SAN1,13-
PLAN TYPE.
CUS1.111DIvi CONS U 10114, I;W$100
PORCMPATIO
$00100 Sig
UNMTED I'M5 01F CONSIMUCT.101%,
P
VERTNUT FERNSUNIMARY
COWT11ALLICTtON FEF 101-000-418-000
PT.AN C'ffErK. PER
[G1,-000.421.000
101-000-420-000
101-M-419-000
R)
,9TROW, m,0'r!QN V PF -.RtiR'0 10 t -W-2.41 -Wl
GIZ r. Im"
TX'VELOPER. aff�./WT H°3'
r
AKr W VUBIAC'kLACE.3 - tt6S11'1' 70 1-000-255-000
S451.63
SUB-70TAI CONSTRUCTION -AND PLAN CHECK
LESS PRE -PAID HES
'U01'A_LPERMff YELPS IMENOW
RECEIPT DATE BY DATE FINALED
INSPECTOR
S5,185.45
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
pa
Return Air
Steel
Combustion Air
Roof Deck
Q 1p
Ir
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
j -Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
17
Exterior Lath
Drywall - Int. Lath
as
/d
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
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
06
Pool Cover
Sewer Connection
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
Utility Notice (Perm)
COMMENTS: