0002-185 (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,,#1,164 Lic. Class , Exp. Da�ef3
Date fir, Signature of Contractor! _
Y OWNER -BUILDER D RATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's'
License Law for the following reason:
( ) I, as ownei 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 I propehy, .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:
() 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 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:
Carver J'.ifijl?➢t,}tu►+. Policy No. tiiw•Ckt o33a
J(This section need not be completed if the permit valuation is for $100.00 or less).
O I' certify that in the perforrriance 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, andaagree that if I should become
subject to 3the workers' compensation piovisions of Section 3700 of the Labor .' Code, I shall fohhwith comply with those-pr,Pwisions.
Date: b le Applicant
Warning: Failure to secure Workers _ggmp nsation 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 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.
1 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
the above-mentioned propeeAy for inspectionpu,rpr ees`..,
Signature (Owner/Agent), Dat;i' ! /'=�-=
BUILDING PERMIT PERMIT ,�;�>,;� '
{ Jh S1 7316 -S7.80
DATEI / j J� VALUATION LOT ,TRACT
JOB SITE? "lu t M11,!V'..,tl ,
APN 4►}i%-.3CJl-Ali Q9
ADDRESS
OWNER ,•
CONTRACTOR / DESIGNER / ENGINEER
^r D DESE..R- T DE VE.1013"4SENU
SPA IRKS C'0_f1!S'('R.L'C`t(GAN.
Flo r, UK ! i!b
'4- It iliVC;I7� S.r'i t �U4iV it{ lJ�
'
LA QUIN A.. C� 902.53
(:<�. t?U1N'("� ; CA, 9225
(700)7'71,4941. C13LJI-.� 996
'
PERMIT _ _ _4Yi
USE OF_PE_fr
b3.�JOLE ,A.N414.Y J��1.INc,;
�x u- i._•�lzt•.rvv �-i-s- i rd�viix a:s �.�c�.� tiwi;a..uv�, e3+.u�; ti avf�t..t,.Y 6J.tt � •
--. l��.:t�A,. !�"ru 1'1.,,e�.N +~.'lr9k::t°.t�. i ��7 kit�.131�it,'1'tC?td krC.� 1ViC1i 1 fi:''f.iE f�«�if.JP.;NC;Js rai?,.. • " _ _ _ ,::,.
SAMF+1..A11T'e'VT1ts,
CrUS'+OM i"CW-M E UCTi01; 2,074.00 Sr
f4i:'ltTiriCAt�t?i�lr'i" ol.tti!<
6151aBii� i E':4:f� AKA.)T OF E'4?' -1 37#7.f g'.fav
1173,6.. l. 0 '
' is:t�i�`;`i'►1C�J't�i'i�l�?:r"llo ' lii�-�tii3�41t3-(l€3ti �mf�S.::�
Gt,ANfT44 I{tipHF i,01-001-439-318 47 t,tg
,MIXIIANICF,1.1.72B 101-000-4211.000
1*!Lt ,:TRK.'Af OR--, t; ►01-Ut?U-420-000 $133A3
PLtJML3JNU f6F 1.01 -WO -419-000 $10.25
-
101-KiN0. 1M(,7•i'f:'y,(-T1rF3'F;iYI'3 01_()W1 ?414)f1f) $1? 17
1.0
GPn/^T),U`;c i i, T; t014,I)C)•421-Goo $210.00
DEVE-LOPER 1AVACT HE 00
.1XR ".1,N 1JUL.t, : VLA.C1:S - f(.ESII: 701-000-2."M00 00 5184.94
4;('JNc11?UCTI N ANT) PI. A7N �'HEC)p1�e
x,11
�!
!-r ESS iC RE, -1 �t1 D lfTSE' S
pi jt�.114j
$ .Vl1
Ti'.8'.QAL P14,RAI V1..7 fl -F, ES J)UU NOW
$4.114.04 ..
RECEIPT
DATE
BY �S'/ r
),
DATEFINALED
INSPECTOR
t-
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
O.K to Wrap .�J
Framing —L�G� ��
Insulation �--l6.6;�
F.A.U.
Compressor
Vents
1-�--��
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath LL
Final / —
BLOCKWALLAPPROVALS
Final
Steel
�O
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 7
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: