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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 #I Lic. Class Exp. Date
Date r. p t 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 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.
(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 S. AiO,n 3700 of the Labor
Code, I shall forthwith comply with those provisiorft' "
Date: -9! Applicant t'� .iy*'\
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 h
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 cf 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 property for inspection purposes.
Signature (Owner/Agent)^ .• �`''` Date
BUILDING PERMIT PERMIT#
VALUATION LOT 0'jt>)�li,�°b' TRACT
oe 63 2,8490-7
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER a
33410C"MIZAGA`Lr.`�'£�'�', TE325
3400CIN WaMMi3 , ;S'l' 325
L..A SP2106
fiiS M"S CA M06
M, lip. 5386
USE OF PERMIT
SHEFFIELD HiatdtPO
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3400 C.M4TftAi., ANT.E`NUF. ,nj ? :i:23
S » 1,010 6-3,PLAN kC;t PERMIT DOES LVOT C1;<fJ.DZ BL•OCZ, WA.L.L,
P001, OR DRIVEWAY .APPRCa. CH -1516 RIMUCT1019 TO PLAN CM.X. FIFE.
CUOTOM CONSTRUCTION 2006,00 8F
PORMPATIO 3X00 sy
A.Ake"G `'f;%APPORT
W149TRUCTION.R11 101-000-418-000 S1111219.50
1 _A71 CHECK Lryt 101-000-439-318 $730.37
MECHAMICA41FRE 101 -000 -4 -21 -WO U45.501
ZI.&CTlitx�CA.Lp 101-0,00-420-000 €.311
tFEE e$11 E6
(�iJ4JJvli37d O R�EZ 10i•5.'Wl-1119-000 $1811/5
S TR60140 MOTFON FER - WMID 101 -000 -241 -WO ing-)
or mo FEE 7.01.000.423,.000 $?Oleo
a1+9FRA."eTRlYYC"t'URZFEZ 225-0f>•fl-►,.d13-342 '$1,9W7.0D
,ART lis PUBLIC" PLACE$ - LOSE 701-0004255-000 $09.29
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'903 PRE -PAID FIMS
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�CiTY CIF LA OU—
Flr•OCE DEPT
RECEIPT
DATE
=8Y
DATE FINALED
INSPECTOR y
INSPECTION RECORD
• OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
_
Steel
Combustion Air
_ _
Roof Deck
_
Exhaust Fans
O.K. to Wrap
Framing ��
F.A.U.
Compressor
Insulation Cf
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
-
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
-
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _ _
Pool Cover
Sewer Connection �V �� ��
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
r ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility°Notice (Perm)
g . CITY OF LA QUINTA
BUILDING 4 SAFETY DEPARTMENT
i 777.7012
INSPECTION REQUEST LINE
777-r1 53
DOMES
1
not -
co.-SHEFFIELD I-IOMES
0106-097
Pwmit Number-
POST ON JOB IN CONSPICUOUS PLACE
INSPECI R MUST SIGN ALL APPLICABLE SPACE$
79-910 CITRUS
JOB ADDRESS
SFU - LOT 63, PLAN 2CR - PERMIT DOES
NOT INCLUDE BLOCK WALL, POOL OR
DRIVEWAY APPROACH
TVPE OF INSPECTION T DATE 1NSP.
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO '
TURN ON UTILITIES OR OCCUPY BUILDING 't
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