9907-428 (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 # Lica Class Exp. Date
/ate.rk ' i A + 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, myemployees with wages as their sole
compensation, will do the work, and the structure is not intended oroffered, 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).
O 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.
STATE "1� fJ' 5U 7-S�Sl-100120
(This section need not be completed if the permit valuation is for $100.00 or less).
(.) (.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
' worker compensation laws of California, and agree that if I should become
sub• �to the workers' compensation provisions of Section 3700 of the Labor
C, I' hall fort);''th comply with thoseprovisidn R J j t
Lo Applicant 1.� l.(a4 4 V
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines tip fo $100,000, in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of. Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon.whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of -this applicaton agrees to, &.shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.,
2. Any permit issued as a. result of•this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and herebydauthorize• representatives of this City to enter upon
the above-mentioned proper,!y7for inspection purposes. /,✓
ure (Owner/Agent) Irt+ ' Date/ r�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 93 TRACT
JOB SITE , APN
ADDRESS -79-3421NUEVOORIV W� 91 t471•�31
OWNER CONTRACTOR / DESIGNER / ENGINEER
C1I.IL'.1°tAN 1' AIK) IW1'LU ATAS ASSOC,1C 4c. t: 9aIRHA1C'I' A14 D WILLIAMS ASSOC., RN"C'.
777'-900 AVERi,E OE THE STATES i7 -M AVENUE OF THE STATES
PALMDESEwr CA. 9221 i PA:L,Ii4 . DESifEIZT CA 87211
C BLO 5203
USE OF PERMIT
WD - LOT 93, MAN 5:0, PERMIT DOFF Nt3T D4Ct.. DE St:t:)CR WALL oR °
X-1101- 75% KAM Ctff—Z- : lt� .; FOR iYi1•f$.:11` PIX152JUANM. OF .tiAld%P• Pl,'M
ME
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IAOR "KHO 78,011 Sr
CrARA•! WI CAKPDXV 656.09 SF
R"SrEAUA JED CQT X31' WNS•BRQ"lIG" ION
148,,559..60
QDNI.�3°MIXT1.i1N ME
01-4(IlD-.418-000
1.00
LAs4 CEMICKF
101-190 39-31S
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SUB-TC3`i!1,fk. COtvlS'rRT.ICriOlt, AN.I.?:t'i:.r Lt4 CHECK
LESS PII 4)AM .FEESS
TOT.M., PERMIT 1FtEli DUE, 'fit W
RECEIPT I DATE I BY = ` I DATE FINALED I INSPECTOR
$4,822'.91
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
6'
Return Air
Steel
Roof Dec A0 d -/.• i it
O.K. to Wrap
/ _ —�
Combustion Air
Exhaust Fans
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
d f ^ 0 3 -dD
Drywall - Int. Lath
/Z.
Final
Final 3 - z - W_
BLOCKWALL APPROVALS
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
Waste Lines 8_� �' 6
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
s -I.; _ 1l
Pool Cover
Sewer Connection
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)
COMMENTS: