0002-202 (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
%674074 �
D9te t '' "7� %7`"Signafuire of Contr
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perju y'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). �.
O 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:
O I have and will -maintain a certificate of consenfto 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. J
( ) 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;
CarrierSTAN? FUND - Policy No. • , , 046=000'%D3a
(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 beic�.e.supject to the
workers' compensation laws of California, anree-tha-f if I should become
subject to the workers' compensation pro`�isions of Section 3700 of the Labor
Code, J slIall forthwith comply with those -pro cions.
Date: `�� f �CApplicant
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.
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,pertormed 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 aut orize, representatives of this City to enter upon
the above-mentioned property for ins pectiornp rp � es. j
Signature (Owner/A�),; ,'� e%y-'�i Date
PERMIT#
B.0 LDING PERMIT . •
DATE VATION LOT TRACT TRACT
JOB SITE �y��
ADDRESS 49'-380 Fd.10 Rmpvc.T�TO SO
N
646-3 i 3s3
T
OWNER
CONTRACTOR DESIGNER EN IINEER
•Ll) JwSEWr Y)FEWL PYsD1
C'AVCOViRVMIp
IPO BOX 1716
79-,293 RANCHO iA QIMNTA DP,
1<A, QUJNTA CA 92253
LA1, UIN TA CA 92233
(760)771.-1941 CBLO 2996
USE OF PERMIT
E9WG1,1' VKfA1LY D'b'V:EI.IN
SSD. LOT 30 PAN VIER - PERMIT DOFS 14OT INCLUDF. SI.,CICK "WA1 L1.S ...:
OR PoOl.
CU TOM CONSTI V&IO'N 2,03 .00 OF
OA,RAGWCARPOR'1' (SF) 9, 00.00
Hfi'I'D AIM) COS'.Olt CrO.Pt5'E 7UMON
7C►13, 0.26
1sER.AJ[%'.1;`KE StMib�i.'4:2.y
CONSTRUCTION FEE 101.000.418.000 V81.00
K.AN CHECK ",E 101-000-439-318 $?09.75
MECHANICAL FER 101-000-421-000 $K31.50
ELMCTR1CAL ISLE 101-000-420-000 $129.113
PLUMBINO FRE 101.000419.000 g11$.00
STROT40 MOTION 17EE - RESID 101 $16,86
rMADWO KE .101-000-423-000 $20,00
D—W LOPER IMPACT ",F, $1,907.00
SUB-IWAL CONMRIXTIO.2 AND PLANCH WX
IX S3 P121r•PAED 1WS
x£0.90
TOTAL PER k -131.5 DU' NOW
S3,; tSN94
RECEIPT
DATE
BY ^
-DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set.Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
—U.
F.A.U.
Framing
Compressor
Insulation
c
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Az 41rK
Final
_ (p —Q a
Final dt�6 - l3 fJ
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&Ile
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 _C_0
Utility Notice (Perm) _ . 21 Vi s(
COMMENTS: