0301-316 (BLDG)LI<.GINI=U %,UN 11"IA%, 1 UM Utt:LAMA11Ur4l
I her "—•ffirm under penalty of perjury that I am licensed under provisions of
Chap (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
7; ; Y1 � 2 '13190 3131 An,
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 Uwller of the property, 9M exclusively contracting with licensed
c�otractors to construct the project (Sec. 7044, Business & Professionals
Code). ��
O I am exempt under Section B&P.C. for this r 'as Iii
,-Date ;%" ( Signature of Owner -�
. C.
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
S coon 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 t:`FATZ YU140 Policy No. 0460i'1,FNIT0009415
(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 /th t if I should become
subject to the workers' compensation Virovisions,.of Sect)bn 3700 of the Labor
Code, I shall forthwith comply with t a prow lions` / -
Date: .Applicant -
Warning: Failure to secure Workers' Co pensation 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
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 agre4''to comply -with all City, and State laws relating to the building
construction, and hereby authorize representatiyes f this City to enter upon
the above-mentioned property for inspection p rho s.
Signature (Owner/Agent).. i�.. ��--:r:..rr�"• -7aie� / "T + : 3:
BUILDING PERMIT PERMIT#
4113.E
�,
DATE VALUATION VM(g) LOT TRACT
JOB SiTE'
ADDRESS. %B(,sUCY. �1ARt'1C3P-�c1�171� 55--�oc34
AIN `
OWNER
CONTRACTOR / DESIGNER / EN (NEER
W('.
I�F:I.. IA�Y 1JfiJ �':iC" 'NL.St Au CX ` dt-ACff?J
1P-01. 0X 1M0
2,133 scrum ifJ.tiSf.C'Fl€ %{1 Aymms, x•So
LA QIIN A c iii
C1AR )D 1;Y `r F1T 8:EA (°A 92001
USE OF PERMIT
ckd'Lr�l.flr .�'UII.a�S�T�
131.0(!. 19: ": + 55.522. V OLtYNTAR`d S'C1tttC UR.A L
VA1.,tiATIO?I .t►#O.EU LS
) COST OF C70N6S*Tr4t'UC:'I10X
710MOV
apt�,,. �Cgy��, g@yy ��(( FFM Q ��p �,t y.�yiI�tRiA
c:f>Nli'r'f1�7G7'1Cx11 FEE 101-000-41k3-000
k3.000
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Q 0
D it
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CITY OF LA QUINTA +
FINANCE DEPT.
t
Lt:519 Ff F19-11AIT) YIM
...: $0100
RECEIPT
DATE / .r
I ,
!)
DIT FI LED
INSP
rr
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
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
f Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
steer
Set Backs I
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
al
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Numbing Top Out
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
Encapsulation ;
Gas Piping
Gas Test
Appliances
Final
--
COMMENTS:
Final
Utility Notice {Gas}
��
. ELECTRICAL APPROVALS
G6 G
Temp. Power Pole
Underground Conduit
/
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
oke Detectors
emp. Use of Power
,
Final
Utility Notice (Perm)