9807-140 (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
Date Vii' 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
performance of the work for which this permit is issued.
(i`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 Y 1-+ i+J7 Policy No. 1371.09591
(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 that7f-4 should become
subject to the workers' compensation prrgyis'laons OftSection 31100 of the Labor
Code, I.shall for,16ith comply with those provisions.
✓Date: YV/Z 1 �� Applicant—
Warning:
pplicant 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 attorneys 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 s
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 f
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 enter upon I
the above-mentioned propert or inspection purposes.
(✓Signature (Owner/Agent) �/ /`y -' Date i /9 A"
PERMIT #
'BUILDING PERMIT
98107-:1440
�/` TRACT
DATE ���/ VALUATION 1 EF!%�i%9. t LOT64
%%%
JOB SITE ;a Ry .x aki,'N�a ;•�
ADDRESS 'i°J••Lli1D svA1.) s�aL`l.�.rZYci�f'V
APN 644-D��2r•062
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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S"ADXS C"(-)xA!'a'!YWC,1J`Yr1t,.T
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0295 R.M. , I4" LA OUINMA DR.
LA f; )tuNTA CA. 922:53
L.A.. (?IJIN :i A. CA 922,51
USE OF PERMIT '
84 13 T 1�11AN +v 2-2 111 ikiYii°i DOES Tv(J'1` ,lNu1.I1.ia� l;j;+:i��: tiV�ll C•S
PLAN !;,'1{tW.KP'W! [t11:13tJt E) 750,4*1•0R MV111PIX LSSUANC'L C+F
)a NAE, 4lf K14 I. 7E,,
t'Ci1�[i1Jr,�b'C NF,11 10JI-000.418-000
KANCTMI k,Fn1B 1!31_�?4?-4*�►�31t3 �1Li?!a0�
L�€f:i�i:liW2+l1C..�';l:• 3� Esh: l(31--��".L »431)1) 5��3.f3@
1~L.1("t"lt1E:f1a. Plic 1.01-000-426-oo? $.129,35
f:?(.iJMTHI CY £ FF iUt (3U0 -d i.` dtif3 Si4 x,25
81.'R lNQ fUEt7°°!!'��f��70.1e? YER « .M31D 101-00-24141M gp
3NFRhSN:uX''?`ii( �:;fIX, 225-000-441-342 $3,817.34
A11T IN L'iJ-13LIC €'J1,ACES - IZESi1s 74)1-000-235-000 $174.15
' A
;:PXIP 1CON3"':l'R$1C"3`[ ' AND PLAN G.M:f,; K
PS A44.&1
� LESS PRT& x' ID F EEIS
AUG 14
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RECEIPT
DATE
tbyl 4,J,
DATE FINALED
INSPECTOR
i
:F
V
A i t.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�j -
Underground Ducts
Forms & Footings
die
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
Final
- UU
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
rQ
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
la 40C
Appliances
Final
Final �tl
Utility Notice (Gas) U�
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 _ cv
Utility Notice (Perm)
COMMENTS: