9910-202 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby. affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Seiction 7000) of Division 3 of the Business and
Professionals Code, and my License is in -full force and effect.
License # Lic. Class Exp. Date
JKV-3V26i
D\tem 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:
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will clothe work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). - .
( ) 1, 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
ATION DECLARATION
I hereby affirm. u * nder penalty of perjury one of the following declarations:
I have and will maintain i certificate of -consent to self -insure. for workers'
compensation, as provided for by Section 3700 1 '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
Sec 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compe nsation . insurance carrier & policy no. are:
Carrier Policy No.
STATE FUM)
(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,
Ishall.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 3700 of the Labor
Code, I shall forthwith comply with those provisions
fate: J1114;1q,_* Applicant
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 prbvidecl 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 (if 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 enter upon
the above-mentioned property for . inspection purposes.
SigXure (Owner/Agent)'I', - ___Date /ZZ& /ez&,
PERMIT#
BUILDING PERMIT
DATE 1 ^ VALUATION sn's"sm.4o, LOT, A TRACT. 2 5953
JOB SITE
ADDRESS APN
OWNER CONTRACTOR DESIGNER ENGINEER
01,14111ANTAND WILLIAIM'S AN-SO.C., D 1C. OLIPHANTAIND WILIJANIS AMOC-IN
OFDE.SrKM"S
PALM D LES L�* K!' CA 92211 PA1,MDru5E1Cr CA 92211
("BIA1. 5203
OF PERMIT
SINULE
SFri. LOT 4 PLAN 1k PURMIT LXQf38 1110T n-WIW�fis &T OCK did itLL QR
F"00L. 75��'REDLK-MQN 41 ON MlXffivel ISSUANCER OF SAME PLAN
TYPE. 10-1 .
TRAC TI, 00NMRIX.1-1014 ZV-2.00 sr,
VORCIVYIATTO 1 110. W V
GARA0FJCAA;U1QWf 638.0 SF
nTIMATED -0=1 OF CONN'TRUC TION
PERNITF FEE SUMMARY
CX)N STP -M-11 ON.PEE
101-000-418-0W
$IM100
P!, A N% 0 IF1.09 M 3
110t-W.D.439-318
NW-K-31ANICAL FIX
-0010-421,400'
PLUMIBMG WE
s1'R.(-,N.0 MCMTON FFY, -.RO50
1.01 X)0- 41-I3OO'
A Jim.
GRAMM; 141E,
FJEWELOPER MPACTFIX
ART IN VVOILV: PLACEMS - RESLE, 701,�DW25:5-GVW:
SRJB*T'(-,y17A.I., CONSTRUCIION AND PIAN C'HFCK
L ESS PRE -P. A I D F F, H S
RECEIPT I DATE
IrOT At PERM IT F "M 3 D UE 14OW
DATE FINALED I INSPECTOR
.. 1.38j.W16.40
$3;162,59
$3.362.59
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings I
Ducts
Slab Grade )
_\,
CLIA
Return Air
Steel }
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
i
F.A.U.
Framing 1
--u .
Compressor
Insulation !
S —t _ pQ -
Vents
Fireplace P.L.
Grills
Fireplace T.O. 1
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
g - i 8 • W
Drywall - Int. Lath 1
$ T -,D D
I
Final
Final 1 y(I�,C�� ('`
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 1
Electric Bond
Footings I
Main Drain
Bond Beam I
Approval to Cover
i
Equipment Location
1
Underground Electric
1
Underground Plbg. Test
Final t
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
I— ZO-00 KO
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I
O.K for Finish Plaster
Sewer Lateral !
Z —� _
Pool Cover
Sewer Connection
Encapsulation
Gas Piping ) .
Gas Test
g ��
Appliances
t
Final
i l
Final
Utility Notice (Gas) q�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures
Main Service . 1
Sub Panels }
Exterior Receptacles
G.F.1: 1
Smoke Detectors !
Temp. Use of Power
Final l
Utility Notice (Perm) t
COMMENTS:
Certificate: of -1.'sul-
ation
Your mm leas been insu" "4 Cent nT*:d.
Fberglsss 1nsQ4tioa:ptaiuc.,s,which are d�ea
fOf toQBy'S Safely. ¢L8IId8I1di Snd tgmGRrOW'S � �: .
FAM glass is inoig c wd,tbem£ace P ee�lY aomsombospbh, so it does no have to be trued
with fue-retardasi chemuals that will Icla6l...
lose thim! effoc3iVt�oess aver time. 'It bw not 6m heated
with chemicals that can corrrJde v¢mng oy metal. Fs¢rglass ill. nct absotb mnistm any will it
Mile over lime as -may edw vnjffgjmmdwi9e.
Slibron&OCror.. O.dtumfildon,Co , Ike
boa. ' ,► aR gs7o: ess aorro X09
Oonchl�a Oil, Secret®ryff'remwer - Or— R . Seely, Jenkins, Preswo—or-Y
Lou Merold, Director of Opemdons:Offlcer
R; means ntdstance to heat now.. The higher tbe- R- value, the vmwa the insulating pma.
Ask your buffdcr for the fact shcct cn R- vah,cs. Keep this oertihc-atc with your other
valued papas, If you ever SCFE time home, this cmdffcW should be passed an to the buyer.
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