0208-223 (SFD)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
Date f,�`"'� N` Signature of Contractor
V5�` 4,
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
r
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'
compensatio'n, 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 S°!': TA 115VND Policy No. 1I41p00C.1202 7
(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 Se tion 3700 of the Labor
Code, I shall forthwith comply with thoseeprovisions. /
Date:« 14? —192Applicant // e .r y .4 r
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. ,
s
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
construction, and hereby authorize representatives of this�Gity to enter upon .,
the above-mentioned property forinnspectionnppp%rpo'ses. 4
Signature (Owner/Agent) //-✓ /� — Date //I '4-'�
BUILDING PERMIT PERMIT #
L-
DATE 'Y VALUATION t 4 riese �'V.+ �a p� LOT �f TRACT
If,*, ?W
-JOB SITE
ADDRESS �r A,W.I�� �.111YA
APN 7MV-24--4-01.1
OWNER
CONTRACTOR / DESIGNER / EN (NEER
.f!.YAW'CA Si' HOME BUMDERS INC
ALL juvib".Tt-ICAhl HOME Br1'LD.ER:3 WC
7 6995 FLORTOA. AVENM
16995 FLORMA Alar i 111 `
PALMMMU CA 92211
PAiIN4 DESERT elk 92213
(f)20"'-7' fA 04 f
I
USE OF PERMIT
.17.90 SY. «;Y0 3TtY.f;MIT DOES 140T :NC1..tDOX 81AC K 'WAIJ, POOL Or,
DK'.€VEiRr.,t1,Y A1'T'IS`.OAC'H. ?S% I3.19fi3IFCED !'3rAN CHECK PEF..1a'OR 'T,41:1'LTIPLA
HOUS&C, alt.ME P41AX
TRACT CONSTIIUCTION pno.o SP
QA1 AQEfGA9VbRT 434.00 Sir
.64Si..div.7X8..dJ1D COST +6e!1' MR+.:R.9.1ii/MMIT
3A01
10.15.703A01
(110NOSTRUC11 14 M 101-M)-418-00€1 $6001.%
PLAN r.HWr, FEF 'Sol -000.439- 28 $1V1,R9
V89 DEPOSIT 101-000,439-318 • 259140
11420 :ANICAL PZZ 101-000-11,21-000 459.00
XLECTRICAL F ER 101x000-426-000 131.19, 8:3
P14DltffKNO PRE 101=100-4'15 -K,0 $12811"$
S', RONO MOTRYK FEE - RES11) 101.00 -Ul-000 91.045
Cx3d t iF 'C4 1? 101-000-421-000
PM1f,1rCf'PER DAPAC .ITC,$
1.)kkIstr1 M iiia 660-441 -145 10fi�6t1
z`'*1'
�':l'1Ati(��'i`TfLTt`�T10. 1T� t }is , J LLQ`
"s,r�� :i.94
ISP VEX.-�?F21J) FEE
4250,00
OCT, 2 X911002
Cfry0FLAQUINTA'
FINANCEDEFF'
RECEIPT
DATE BY ((��� {
DAT F7 '` �%
INSPECT/Q/F/���
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
o
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Insulation
/� �, Q3 ljc
_ W`
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BGG
Final S� �l(�
BLOCKWALL APPROVALS
Final
POOLS -SPAS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Server Connection
Z d
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
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) _ v6r �L-1
COMMENTS: