9807-130 (SFD)LICE NSED,CONTRACTOR ,DECLARATION
I hereby. affirm under penalty of perjury!hat 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
112
�4�
Date411n,CPfb 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 , 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
perfor ance of the work for which this permit is issued.
(VI 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.
(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 I should become
subject to the�workers' compensation provisions of Section A' 0e of the Labor
�odeff s II forthwith comply with those provigions'
Date: Applicant 1
J
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. P
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation...
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to en er upon
th C".1Wn above-mentioned property for Inspec'o_n purpose �!J
�
Signature (Owner/Agent) Date
- - - -rT._. PERMIT #
BUILDING PERMIT
(?ATE ' 311$ VALUATION �yq LOT 11 TRACT 251 IL`
JOB SITE
ADDRESS 49-17 �t ci
APN
aiv
)WNER
CONTRACTOR / DESIGNER / ENGINEER
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k1a A C 11r)11Sr1r1111V1""
P 0. 1k_PX 1;10
-751293 RANCHO LA QUINTA DR.
LA (,tJIN•FA C'A 92253
1.A 00INTA CA 92753
USE OF PERMIT
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tr1 1! H.AN 1r i& lAhkM11 lh_*, 3 hK) i INt_ LUL+ WALLS t (
NK XJC. PLAN (''P"'.k F H li OXK. ) 71% F(* MLJ1, t•1PUi 1&4UA ,*', OF
SAA& PLAN TYPF
LVST,LW CONMIX i ION -03&00.';F
(iAftAl.tWCAitt'vk i `x00.00 8F
INTMUTED UTD COST OY L*OPdSiRIXTION
116S..'4i016
sl'FA1l IT i1!U:SfUMMARV
C—V.W3TRiKMON FEW, t0lAXX)-4l8-0W xaN1.t�
P1 AN t'FW(—K FFF 10 i • (i(9fi-4. -?t I R W" 44
hi1XI1ANIC:AL F03 101-M-421.000 $53.50
!% - "13UCAL FM 1014104-420-000 $129.133
PLt $,$3m irLtE"s 101-000-41 000 $136,00
nfKf WITFOW FFF - RiRm 101 0(111941-;ttX) MI6 MS
GRADM E41T, 101-000.423-M S20.00
INFRAS'iitiK,°II)ft FEfi 2254000-443.342 $3.7n6o
ART IN PUMIC PLA003 - RIVE= 701-000.23.5-M 1171.411
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Ri I�T�11"Ai . CY}N�S'R! .1C'1'K11ai ANS PLAN ("i•iW('K
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S,i �7fA �i3
LESS M, -PAID FEES
WOO
TMAL'PERMIT i11:IF4 DUE 1('AIV
:5 IL"
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A
RECEIPT
DATE
BY/J'�•
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- —Age
Underground Ducts
Forms & Footings
G
Ducts
Slab Grade
_ L -
Return Air
Steel
Combustion Air
Roof Deck
_ Of
Exhaust Fans
O.K. to Wrap
Framing
F.A.U.
Compressor
Insulation
-
le
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
t
Final
Final Icy,—
BLOCKWALL 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
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
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: