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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of j
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
/atet-W TSignature of Contractg,�;"
w i.
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 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 Policy No.
GIfai.DE111 JAC—i.L;
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
de, I s all hwihcom I with those PJa
uisl Ls-n
%%ppcaate: .
Warning: Failure to secure Workers' Compensationoverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to '
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I,agree to comply with all City, and State laws relating to the building
constu tion, and hereby authorize representatives of this City to enter upon
Zignature
bove-mentioned property for inspection p rposes. {•
(Owner/Agent),- • / r! • Date
PERMIT #
BUILDING PERMIT
«x�>_�►��6�
DATE VALUATION .%d LOT ;) i TRACT
JOB SITE ., „
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P`i7ni'!'T t's'[r i .Slll lkq ;: t r '."IA 31l fT iRll'i'V'r'i
d L.lw\t ]Y 'v,�I. tl..l.JaY IJ tlJ tJI'rJ J'Je,.49
r Ali 1'IY iT) i r_ 1,h ., {f1 i T Y"ili :t'A T't'IAT 'YY 1; 4
\.lil . t I11., l .,..dt\l tll MISM /,..J 111{4l.VtvJ [ 1lw A!
.1.33 SO.' r! 9.. LEis?; SLE, 000
11515 SO. 4D11 SrR 1Ml; S"i`i;,11,200
SAN l3ERNARlllNO CA SQ1108
SAN18E NARliINO C.A. r,408
USE OF PERMIT
W -TJ, D 1 i 9`I'E, !'IFMN `ilii, iai vll ,1' tJl;ttil 1v%� ..i�i41.7I1A% rl',: iCpo "
WALLS (1R KJOL. PLAN CHECK 1111101VIX,
f; AVA'NCR (5F SA&tE 1A. -AN TYYPH,
"1'12i,C'T CV_-TN3*1WC'i ION 2,240.(() SF
36,W Wl
UALBAORIC:ARPOWf^ ti y$, K1 Sh
Y..90
1`1 i�ADT FEE S$1[!MARV
r:,C>i+fS't'1ttJG: I"it`)N f EF 1.01-000-418-000 $752 tN_t
N11-011 I f\,J, t�,tw, l Qcf. �ll I_0001 -.III, sfta $D. 50
F EC"i.`P.ICAL MV 10,1-000-420-000 3.i39.no
PLVMD, ING fr&.' (01-000-419-000 $1523.5
XMRO3Tvv�IG Ntl,•�'t�*^tON }; f.. - 4.l':�70 -l�1$n�r(�t.?14I-yQtilu�ji 1�a t2,JtMK
11..}.
€!1R4k , 1KG .I':Z E 101.`V1.Iir^'423-'4 00 .g4U.�ii
t13i" fti `iPSZt3C'TtJEtli V1s0 x215 000 443-342 S3,01.6.776
Ait1' 1'N PUBLIC KAC3RS . RESte 701-000-255-01)0
,lft ``+^(`s1'AI CON '1` 11{:°Y' ON AND NJT _N. f Ii'iFtC'*K
$4 40tiJR
b � �
p 6(++gyp ,,tt q,y y� FF�I p g' NOW
o- �^ TOTM, F IPTA4111' .�1 C!.F—S (WE i�•�:1�7•
SEP
SMaY`OYi 0.. r.�
RECEIPzT.
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
p • 4
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap //
F.A.U.
Framing w .
/
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
BLOCKWALL APPROVA S
POOLS - SPAS
Steel
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
—Q
Encapsulation
Gas Piping
Gas Test
2
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.L .
Smoke Detectors
Temp. Use of Power
Final
• Utility Notice (Perm)
COMMENTS: