9911-111 (BLCK)I" -
N
111
�a�
Lu
�it
C, Z n
0
J U
.w LLi
F- a
CO)
Z.
0
LO
X
m
d
CL,
co
LO
N
0 N
MZ
FZcro
J J
J Q
UV
CD
Cb 5
N_ n
LICENSED CONTRACTOR DECLARATION
f hereby affirm under penalty of perjurythat 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
3F31 $�l
C2 i) 07/3i/15r�
'Date. Signature of" Contracti5r T� - �
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I•am exempt from the. Contractor's
License Law forthe 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:
.
() I haveand will maintain a certificate of consent to serf -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 ot,the work for which this
permit is issued. My workers' compensation. insurance carrier &'policy no. are:
Camp f3tkVVI t+ORD Li:? DEIVA 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 Califomia, and agree that if I should become
Subject to the workers' compensation- provisions of, ction 3700 of he Labor
Code, I shall hot comply with thflse 7-41C,& vlslo
1r Datef! Applicant's 7' f.�i�yf
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crirninal, 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 underor pursuantto
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.
certify that,l 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 repres tatives of t • City to enter'upon
the,above-mentioned property for inspect!' pur ses.
k_Signature (Owner/Agent `- Date-/ �Wy
BUILDING PERMIT PERMIT#
DATE 111,15119/ALUATION LOT TRACT
JOB SITE :f's-� f �,� rl`cl"i.� l �A�°
APN'
ADDRESS .
OWNER
CONTRACTOR / DESIGNER / ENGINEER
',.A�! `YIIfl1.,�7At"j
S. k.,1W.T."FEUCK" ':. NNI.3 `;t�w Illy
09 SII It.l i l'I�1E f_`-I11t�1�
662 DF, LA(30 Ci R, N
194•'
PALM iy}<S.t:R}' C.A 92,25.S
l7ts'f)jfd3'; �23t�i CIM -114Y 55413
USE OF PERMIT
t "rC►1•,.F. 6. (U) i AfkLC£iv VVA.i.L , 114) w..(1•)) CUi%Q% o 'FALL - ORCO
:i PT. W,41 1':C; (4) L
EFT- trvALL wo.6 ix,
A
ki ,'R KD COST Or CON4`fRU'+L~110N.
71,750.0ft
s Y�AN3*fRIJC.11' ..)N FEE 101-(1f!!f-8319-IFiiit 499.ik)
,;f 1R. TY]r-M.. t:'f:?'�f �+i?f,C iC"}'}"rJ�f AND PLANT C11,FCK
S99 ire;;
Lf', SS €'in', -PAID B-7EN
N
a0.fm
'3k'O'3'AL Pl~;RNO I. #1i4 VInti NAd):6�: CStit+'
1 .G9f
RECEIPT
D
} i
BY %/ .1
DATE FINALED
INSPECTOR
INS�ECTI��r� �ECQQF:D
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
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
Final
SLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs —
Electric Bond
Footings
Main Drain
Bond Beam IVApproval
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALSGas
Tes!
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: