0207-128 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that] 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 �'� Signature of Contractor "A
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 STATE FUND Policy No. IF16$$2-01
(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
Code, I shall forthwith comply with those provisions..--
Date: r /. s Applicant—
Warning:
pplicant
Warning: Failure to secure Wo
rkers"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;
whose request and for whose benefit work is performed under or pursuant o;
any permit issued as a result of this applicaton agrees to, & shall, indemni `
& hold harmless the City of La Quinta, its officers, agents and employr�s.
2. Any permit issued as a result of this application becomes null,�and vo cif
work is not commenced within 180 days from date of issuance of s ch
permit, or cessation of work for 180 days will subject permit to cancellatts�
.
I certify that I have read this application and state that the above informatio
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.
Signature (Owner/Agent) `�. !?!} -rtiy �� Date'r�`'.`
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 1 TRACT
o�i��
JOB SITE� t�p "r��
ADDRESS ;' fi? Wiry liU
0
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SEIFINFLD HONIES
251 -07 -MELD HOMES
3400 G' TM>AV_VWTE VJ."r", 325r
1dIV : txB C.A. 925{)6
R.lVTM:MI F� CIA 92506
(909)682-5362 MUf 53E36
USE OF PERMIT
5PO • 1.07' 1, P1 AN 2C R. Prr.M71T DOIWOT ,NCLU`J0 •, liL X.r. WAi,A,`,
ij00f, SPA OR, DRIVWAY AiDP,ROACT4
CUSTOM CM43TRIICTION Z386-09 114F
PORC HIPATIO 321,00 SP'
WtiI,hOldw C, PPOR:b' `:- 540V fit'
�n?:�9111MMO Cot -IT OF CC'MM7UMN
1,39,7'f'.2:.+Gsk?
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�.63+.i•416y7d..�f .7t 16a[r� ��'L�S5fD1X,0.0A,L.`L
CGN31'RUCTI'0141"M 101-000-418-0-00 *11W310
F1,AN d;.t°1 ECK FEE 101-000-439-336 $915.49
V:ECH N1c ", Vr9 101-000-421-000 ISS, SO
✓ Lf!aC;'?TPJCAL FES 101.,000-4•20-000 $Y&.31
PWMA 40 PF -1 101-040«419.000 Wt,75
:i'i'iiONt4 MOTION PELT•,iL 17 !!il-a0U•1�%31-AQ(� $V.9i
OR,AOlWO.YUP 101,000-42.3-000 � 3:t►,Slit
I'3d�':#Ee�'�1`1'12.4��:mlt';i?L' >i;`l�•�::.� '�2i•d9U4Z••�-:�-3��' �2,�195,i10
,
.AlCf 91 PUBLIC PLACE - RESIL 270-000445.000 $49,29
Ana A V9VL-`i t "1dL t�'��:si.�'�""]t",�W.3hi' MTD 1'iAl+T' 01101.CK
:G5,02A.10
3 M., MIMS
$0,00
AOR T(YrAL PrAWT MS MIR
CITYOF•LAQUINTA
jFINANCEDEPT.
RECEIPT
DATE :
BY
DATE FINALED
INSPECTO '
OaO7 - 1 ' LO INSPECTION- RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q Z
Underground Ducts
Forms & Footings
( (
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
„Zy-6�Z
Exhaust Fans
O.K. to Wrap9,9j2—
F.A.U.
Framing
!�Z
Compressor
Insulation
p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
`Party Wall Firewall
Exterior Lath
p�
Drywall - Int. Lath
Final
Final
POOLS - SPAS
' BLOCKWALL
APPROVALS
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
C
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
/
O.K. for Finish Plaster
Sewer Lateral
J
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
--
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) —
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels t_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)