0106-096 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of pe jury that I am licensed under provisions of
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
LU Professionals Code, and my License is in full force and effect.
O c,.) 1 License # a Lic. Class Exp. Date
rl Z r- Date • ' t t 1 Signature of Contractor � 0y�• -IA
L) OWNER -BUILDER DECLARATION
m
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
( ) 1, 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
L
N Date Signature of Owner
ON
0)
CL Q WORKER'S COMPENSATION DECLARATION
o2 Z
I hereby affirm under penalty of perjury one of the following declarations:
U') HCc
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for;by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
Go Q L) ( ) I have and will maintain workers' compensation insurance, as required by
O L Q Section 3700 of the Labor Code, for the performance of the work for which this
rn I- permit is issued. My workers' compensation insurance carrier & policy no. are:
19t Z Carrier Policy No.
ago CY ' . , 3`1'a®,,',l R M;D 11ia159.2411
Q (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,pro"visions.
Date: f , • , S Applicant �•. "V (�. >s�, W 1/ 1
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 foes.
IMPORTANT Application is hereby made to the Director of Building and Safety.
for a permit subject to the conditions and restrictions set forth on_bL
application.
1. Each person upon whose behalf this application is made & ea e on at
whose request and for whose benefit work is performed under or s t to
any permit issued as a result of this applicaton agrees to, & shal • e nify
& hold harmless the City of La Quinta, its officers, agents and loy es. JI
2. Any permit issued as a result of this application becomes null vo d if
work is not commenced within 180 days from date of issuan a of s ch
permit, or cessation of work for 180. days will subject permit to c cellati
I certify that I have read this application and state that the above inf rmation is
correct. I agree to comply with all City, and State laws relating to th". Uilding—
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspec� purposes.
Signature (Owner/Agent e i 1� fit Date - '
BUILDING PERMIT PERMT#
D VALUATION LOT 01()6_ TRACT
I .' ` . tiSl Z1 rII-1
JOB SITE
APN
ADDRESS
7.9-91N) MUS
7695-T2AI -n1.1
OWNER
CONTRACTOR/DESIGNER/EN (NEER
£ OOLD 1101S.8
at -MRS
11,YVCdRSWE ('°h 1?2506
'MNIMS4'D, �`,A 92SO6
('909)582.5352 (31A414 33116
USE OF PERMIT
8111;CF,6' EL -D HOMIM
01NC"SU FANL ' { MUG
;34O D CEN TRA 1, AV -%r.4URP S` I 32:5
r
SFD,.) 4?1 54B- 4x1?; -PERMIT DOES 140T 11VC1aUM, F3WCX' +6,f1'a,1;4
PO1, a, DftWWAY AP eH,
C':G13TOM CC," 1ST UC` ION IM02.00 8?
Pi7'RC+KIPA.' TO 300,03 SP
gKRAMMARPORT (FSP) 1$481120
Cu' 33T OF C ONTARt7dI°'J> ON
; M.221AM
.PRI �':^��I ;CZE 41.1AWARY
r.;CYNSTRi1CT1'ON WR 101.000.418-000 S18196.00
KAM ICHI;CX FEE 101-000-439-318 $96$.97
MCM.AN1C"rAL= 101-000-4.1.000 S+O&50
113XZT.R1CA1...; EM 101-000-420.000
PLi.1MEW3-0 fTE 101.000.419-151111 8183.00
ZR 0#C7 aV10T1CQk4 P1✓9 - =— r1D 101-000-°241-C`i#~ 0 $21.011
-sit, ,x,511` a Ira 101.000.423-000 $20.00
MMST3t1,aC"ri11i1?;I= 225-00 44.3-342 $1,901.rfo
ART IN MUM PLliCY91-1M11: 701 -(WO-255-000 $1,431.30
• 1 «°" '!`,9,1, "1�1�i"°�'1nii WA�ti63N L x3�
$1.,718.39
1N 1 5 2001 LESS MvPAID FM
50100
ITY Of LA ouiNTA
!i
FlNafd..._--cE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
F
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Return Air
Slab Grade
Steel
Combustion Air
Roof Deck _
O.K. to Wrap �� �j( _ !�
Framing _ G _
Insulation
Exhaust Fans
F.A.U.
Compressor
Vents
(/
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Condensate Lines
Party Wall insulation
Party Wali Firewall
Exterior Lath �y
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
/' Sewer Lateral _ _ _
J Sewer Connection ��'� (
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lary Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.E.I.
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm)
s CITY OF LA QUINTA
= BUILDING 14. SAFETY OEPARTMENT
777.7012
INSPECTION REQUEST LINE
M-7153
SIIE,F f IELD HOMES
'FIELD HOMES
V
CQAtfi1C10� � ' v
emit Number
POST ON JOS IN CONSPICUOUS PIA E
INSPECTOR MUST SIIGNLLAPLICABLE - PACES _
J09 AODAE
F�S AN 3AA- PERMIT DOES
�NOi�T INCLUDE BLOCK WALL, POOL OR-,--
DRIVEWAY
RDRIVEWAY APPROACH
i
e
ABOVE APPROVALS 00 NOT INCLUDE RIGMT TO i
TURN ON UTILITIES OR OCCUPY BUILDING
Ze-d
T8VOV990941 snzjiI3lIA08i Wd �£:£0 T00Z-90-03Q