9807-058 (SFD)f -
N U)
W
d
W
o Z
�00
H�
W W
I— a
U)
Z
th
LO
N
ON
U_ °)
0_ Z
0,��
r l- 0
0 J J
m<
O
Il rn H
Z_
ab / )
.
�:� 0
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
✓Date 07Signature of Contra''°�,'/
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 ownerof 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.
(4 1 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.
��'^.}t r �te:i Y•.1 ti, �ta,.;.
(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 o Sgction 3700 of the Labor
Code, hall Yiwimply with thos p ovisio s./
ate: ' ' `'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 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 atilt
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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned proper ty-fo , nspect•on p rposes.
_/S1 ature (Owner/Agent" ). 1 Date ��
BUILDING PERMIT PERMIT# 4 A
�1�Ii7-ii5
DATEf VALUATION m3o wo4zo LOT - go TRACT .79,k)
C'
AbJOB
1/1.,4
SITE
ADDRESS' { -156 Capt OV CCA3E4
APN S►►t �-3bL 1iJ
OWNER
CONTRACTOR/DESIGNER/ENGINEER
r't.:i•ri4±i'l'vr�J)r`►t.trt:ts �'YL►on,ssiwttrt•tr:r
�.. 1.aa l{�lt�.± .,..e4eJ a9.k4, r,,, 1. ±ativ,b r'aa. t.,e,
r=);rra•�-si►vr-nr���rj t r+�a.st,rrrt�s:��{rad
.,, t9a .ii,f. ., w.r\4.• �L, �. ,mli.tvay.t asa.
1:359 W. Ib." IS•1RE11i•, SIT,, 92(H)
i535ISO. "0" STItEFT, Sjl' E. ra200
SAN Blsld.NARDINO CA 9.2409
SAN PERNARO 190 GA. 924#)R
CIRL/f MID
USE OF PERMIT
:ss',.f l :LOJ: 0 48iX ,i%bViR MR- i°6W1 k r Fs NOT. iidr;;•L DL psi ock
±JVAIJAS OR I!L'►f J,..PI.AN CHUCK, Vu--, IWf)itCV00 7-V/o FOX Emm'!'fi�1..};
IS'it3ti:f;CR Of `iAWO', Pt,AN •TYf0K,,
'i'ttilf� a i.`t;rAi� i`iL�i:i::i'.i�N 2, iuc�•(h� `»
Z.3A (A0VC,A1tV0R L' 634,00-S17
Ats1�•.l .lA�:if�.i .bi.1.4' i�"AMiJ•i• '11COPOIN OU11 ��R �01i ,'
,4.Yim�Si�( .6Vf
PERtaO•p ,ila tt EP SUMMARY
(:ONSTP.LY f!ON FEE 101-000-418-000
N4Rr_'��: ,1CA.t.FI&E '101-000-421-000 an5i.�t)
E:LEX''"f RICA6.1,11;8 101430+3410.000 S.13t�.y9
PLL WHIING RUM $1.M_75
5 1�( aN(s hit '!"tOi�f F"i?t'~:, r R -F -81r) 1123- (}'Q4',,0M S;t 1,04)
Grztu)Na frim:1D1-f3G:7-�2 OsjJ sa�.r ►
iN.Vkkq.1'RI,1& 7rLf.ttl, FFM 2'25-000-443.3Q %1,92.5.x'()
AJ0. dN' 1" U13L.1*C PI ACES - ltESWt 701,-000-255-000 $15. 10
S(,rpt_1'�1�'t1i.trliMM°1IC7?vAND !'!,AN (~l -f i'itri,2l
.2?
aLESS F'1'..1-V..Mt3.FIst 5
�a t
$ii.00
�S �:3TA-1a PERM11- Ti -EY f11ifH. 7OIOW
;��b,E€�# 127
it
SFJ, CEIPT "DATE
"
BYa '
DATE FINALED
INSPECTOR
i
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ !�
Underground Ducts
Ducts
Slab Grade
�-
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
— i- Q
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
Drpiall - Int. Lath
/ •�iI/L
1 17
Final
Final
BLOCKWALL APPROV 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
Off 74Plumbing
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 Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of'Power
Final
Utility Notice (Perm)
COMMENTS:
i