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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
66.6895 U U-101?.Of
Date _�/��f 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:
( ) 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
ontractor "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:
Cartier Policy No.
u.113�'ZIOR. NX 1'10't:A WC117p033A►
(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: �.0-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 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 f
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agerit) %' Date���
r 00 BUILDING PERMIT PERMIT# `
! 0 i6iPU.fm•Ei3`.�
,YATE VALUATION 0 LOT TRACT
5239,7116
JOB SITE
ADDRESS 79L-60 CT�ifIN
AP-N�7/ q
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
Cf tt'C;l":#Y,'1.1-, "2Tf)h tt::y`
t..liLrA,i .. J il\
L+I11� Tt:T t'� LTI-11 Is
F i t.+l/t TtJ� Is
34W CENTRAL AVENUE M X25
3400 Ub a RAL AVENUL' !M 323
X1VF*KS1Dh' CA 92506
It1M11IRSM, C,'A, 92506
l<1(1c1-535'x CEiY.�E 53.g(
`
USE OF PERMIT
� �fVla.l.la FAMILY DM31I G
(�
31 -D -LOT 32TLrii 2C--1SR&flf DOES NOT INCLt3 k i3L0C_ .WALI, OR
L1iAsL..75;4 PLAN trilL:�.,.F�. FF,,e 1.{hOUC:YIOISI 1�'01( M.1)I.,T1PLH ISSUANC;i� OF
SAMB 131LAN'tYPI:.
1?0RCi.fiVATIO- 3 rl!N1 ik
ixALtrlC W(;Akd"ORT i4omu SH
i5 t 4b��wLY COST ilY� K-•i/!'�e�.Y Y,4E4`�� W L`V1
4p.%� .�il�..it
0N5'f ki7 ].'10N FEG 101-000-418-000
CW. , r FW, ) 01 d/K�►H/�1-4{�2'3-(; 1 RR t1lf)167
.
�PLAy�N
11y1;1.i ANR1. AL 17013 10.1-0,00-4211-000
1:sLE�J I'fq CA! TM 101-000-420-000 3 i�8.31
PL.U&*J1N(.* iii 1, 101 -WO -419-000 $ ibt.75
STR0N0 MOTION VEM - Kr;ST!) 101 -OM -741-000 V23 97
0RAD[ ,'O :r'i; 301.000-423.000
iKFRIlS'Clit3Cftil FM 225-000-443-342 $1.!A) 7.00
AAIr• 114 PUBLIC 14 -Am - RhIN11701-000-255-000
LL i"'�'It-RAID l�FM
$0.00
TOTAL PERK11 FEES OVE NOW
fi4,1�S.t�B
RECEIPT
DATE
Y f
DATE FINALED
INSPECTOR
INSPECTION RECORD
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
GU
F.A.U.
Framing
Insulation
Compressor
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 APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I I
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
Encapsulation
Gas Piping
Gas Test
Appliances '
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Ma,n Service
Sub Panels
Exterior Receptacles
G. .I.
Smoke betectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CITY OF LA,.QUII A(,;.,
°c BUILDING & SAFETY D1�PARTMA XTP),
777-7012
«., INSPECTION REQUEST I'UNE
777-7153 51/.O'
Owner SHEFFIELD HOMES
Contractor SHEFFIELD HOMES
Permit Number 0003-039
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
-:60
JOB ADDRESS
0 WElp 0- RMIT DOES NOT
INCLUDE BLOCK WALLS OR POOL
TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
2 —,--d
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT- A/C
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP -
GROUT D 4' O 8'
FRAMING
INSULATION
PRE -R OF
- 4i JA 0e:::AI!_
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR QJ
EXTERIOR LATH
POOL PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK
� - FINALS
ELECTRICAL
PLUMBING
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING