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LICENSED CONTRACTOR DECLARATION
I her affirm under penalty of perjury that I am licensed under provisions of
Chak,_ (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
'73.1,152 B t' VII
Date 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 & 13.pfessionals
Code).
( ) I am exempt under Section , B&P.C. f this f-ea�n%
Date J- .�5 I r f, Signature of Owner.- :✓
WORKER'S COMPENSATION DECLAR TION
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 STATE FUND Policy No. (460 J,VN14'099413
(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 Californi , and agree that if, I should become
subject to the workers' compensation provisions of Se loKi 3700 of the Labor
Code, I shall forthwith comply with thosQtprovisipns: `'
Date: ! E '' .;,Applicant _.) /
Warning: Failure to secure Workers' Compensation coverage is unitaw,fu) 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, indemnity
& 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 representatiyes of this City to enter upon
the above-mentioned property fo inspectior�fpu (poses.
1 A.
Signature (Owner/Agenty-' 4 Date E
BUILDING PERMIT PERMIT#
DATE VALUATION $ fa pM LOT TRACTo
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ADDRESS JOB SITE 111.125 a.iCL`IiA I'di3I1T' - I!%IN" fir �5_3 (p a
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PIG W._ , i t,EXIA 1Ii'sjkAlkM. , INC
M.. MMUPAt` FIC" OHNI :i3JU, 01014 T id
P.C3.1 OX, 1(160
25 33 .110UTH CO.�rOT kSTtHIWA`C'TST"- 250
1,A,QUIMA CA 92253
c.AU),114- 3 TIMr SEA CA 92MY7
( 60)635 .,1010 COU; 3823
USE OF PERMIT
Nk-NEIRAL Bll.tLD1MG
HI,,S:aCp, d.5:.�. °.�" QS•:v18, 5Sn3,1d, Ski.?3Lt. "�''OL,Li�J'rriti:Y
STRUCe' 1R.a&i.,MODIFIC.Pz`i'IO'NS
if'.I I -VA' ION 14,itZ0,!)0 IJS
_9911hullej) Cloly OJ[' COlVYME7f.'T ON
14,OW.00
Pu."VITEE SUMMARY
CONSTRUCT)CM RKE 101.006.410-000 $03100
S'TRCYNO M0710N FEE- R.ESID 10l-000_241-000
;I
FEB 0 3.1003
CITY OF LA QUINTA
FINANCE -DEPT.
i
;711` 3-1'0)'3"AI c"t�Al lir.,C b1Ci A 1�:►�I.At3 K
$154.40
1u1,3S 'PIRE-WMFRUS
WA)
'a'WAL MRWH IMI S DUENOW
$154,40
RECEIPT
DATEBY
D E F
ALE
INS OR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Farms & Footings
Ducts
Slab Grade
Electric Bond
Return Air
Steel
Bond Beam
Combustion Air
Roof Deck
Equipment Location
Exhaust Fans
O.K. to Wrap
F.A U.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate tines
Party Wall.Firewall 1
Exterior Lath 17 rh, Q _
Drvwall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings �
Main Drain
Bond Beam
I Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
at
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
I En:apsulation
Gas Piping
-
Gas Test
Final
L ` ' ELECTRICAL APPROVALS
Temp. Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
J.
oke Detectors
emp. Use of Power
Final
Final ,
COMMENTS:
Vl�lWX l44X1/13