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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapt r 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals'Oode, and my License is in full force and effect.
License # Lic. Class Exp. Date
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Date 22LzF Signature of Contractor �'%� ''5�~�
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 Policy No.
09TATR 046-0-000703M
(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 forwhich 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 thaLif, l should become
subject to the workers' compensation provisions of Section 3'/00''�of the Labor
Code, I shall forthwith comply with those provisions.—
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Date: y �'. ,. Applicant /. �:sf r 5%'
-7'� �,. • fir,,. �, cr• ��✓'.,/,••
Warning: Failure to secure Arkers' Compensatlon'coverage is pnlawful 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 A'
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;IrrorrYaQ
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 t is(City to enter upon
the above-mentioned property for inspection ,pu�poses
Signature (Owner/Agent) ' ! • "� �'� - • 'Date Z- •w 1' 6
BUILDING PERMIT PERMIT#
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DATE/� r f VALUATION LOT TRACT
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sn'W-MAn 47 itP. 0.x
JOB SITE
APN
ADDRESS
574Sir;7 C01 II,1>ff"_f1
��ik 4-17 ►
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1J1W 14OFFM
1; i ; '; 400) aON com'Jnuicnow DIC.
50 1 KTRR RIDE CLIM DRAWL-
73011 CQUITrRY CLUBIA, MIXE-14
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W"M kwax 1:C. 60421
P AU1. =871 1PIr CA 92260
'(760)346-4.032 (MLIt 10-44
USE OF PERMIT s
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IripC'.fti3�.{yy$3,r fyy�y�14�s`�N5Si '��`/�hIf.�"/Yyh{� �s.�tA♦A�f��Y4'ityC�:�A.Bit`p
eS��ri.&LA,,^,,Ei�p9
L".cA+ETER AE`IG!('!:l�.' ���-14, ./L Et•�UIP-'IEA"!.1 FRe-7.N�iA1: R 13 T�h.T 1, I`t�e6Ji7{.�T.`D '
AN HIE PERMIT
13100,AtWOR MIA 67.,,908.00 LS
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ESJ.%J.iJdT'.fTED COSTOF C01191RUfl,i110
412e909.hd9l
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PLAN CHF.GK RE 101 -(A)0.439 -31S $30.45
C01-48TALi;t' TION FRE 101-0,00.416.000 $473.00
MECHANICAL FEE . I'wl; �'aA, 101 -000-421 -000 $24.00
PLUMMO VZF _.. POT 101.000-419-CAIO .00
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avw>r'tyrh.i,':ownI3amS: x -Atm py'm Cul %ex
W76,45
L EVU PRE -PAW 1EX-)
$0.00
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RECEIPT
DATIft JA 1B.
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DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
', BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F,1ms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
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
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
POOLS - SPAS_
steel
Electric Bond
_
Footings
Main Drain
Bond Beam
Approval to Cover
Final
PLUMBING APPROVALS
Equipment Location
Underground Electric
Underground Plbg. T t
Gas Piping ,Ai�
Gas Test 0�
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
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COMMENTS:
Notice
I ELECTRICAL APPROVALS
Power Pole
around Conduit
Low Vot
Fixtures
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
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