9907-430 (SFD)i
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.# tic. Class Exp. Date
Signature o Contract .Date f C o t r.
OWNER -BUILDER DECLARATION' . .
I
ECLARATION-
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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).
1, as owner of the property, am exclusively contracting with licensed
contractors' to construct the project (Sec. 7044, Business &'Professionals
Code).
O •I am 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 declarationsf
I have and will maintain a certificate of consent to self -insure for workers'.
Compensation, as provided for -by Section 3700 of the I Labor Code,'for the
performance of the work fo r which this permit is issued.
I have and will maintain workers' compensation' insurance, as required by
Section 3706 of. the -Labor Code,- for the p - el'formance of th,e'wbrk for'which.this
permit is issued,. My workers' compensation insurance. Garner &
policy no. are -
Carrier Policy No.
STATE FITND df s,.�a3-tlttc�0.12n
(This section need not be completed eted 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
b'Ydtothe
_I workers' c
ompen
sa
tionprovis
ion
s,of ection 3700.of the Labor
e, 1allI 7', wI comply with'thproIS;a . !I I 56 nnfinnnt#
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 3766
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 Jorth 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 is ' sued 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. *1 agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the ab-ove-mentioned property for inspectibr, purposes.
�
/ignature (Owner/AgeeD a.t, t V
BUILDING PERMIT PERMIT#
W
- 9)7-430
DATE VALUATION LOT TRACT
95
JOB SITE APN
ADDRESS 79,302NUEVO DRIVc
I OWNER CONTRACTOR DESIGNER ENGINEER
ASSO.C. . D4 G. '"Raf.i,wis, Alssoc, mc.
.77-3ii{).A RN ri-MO.AYPNUF OF THE STATES
VE qJE
PALM Dl?.SERT CA 92211 PAL&I DESEXf CA 92211
(7K)345-2626, C-81ur'? 5203
USE OF PERMIT
SFD - LCre 9J5, 4,P, PERMIT WM.L
ORI)OOL, 7,`P/*PT.AN C'FIFIMURIF F011. MULTIPIX.FSSUANICE OF SAM.F,
PIAN TYPE
.1
'f RACCONSTRUCTION 3.094'.010 Ica.,
PORCHYPATfO Z-00 s1r.
0ARAGFJCiW0,R,T �iF
43TIMAIT,'D
PERMIT FECESUMMARY
CONS" 1.RtfC1T10?1 17ES
t01-CV041.8-6:"{)0
$7=11.00
PLAN CtIECK FF.
101 0w."139_318
5154,30
&ECTf t W AL.FL76'.
STRONG NIOTIGN HX 4 RF31D
101-000-241.400
112.02
OT ADING FM,
t01-0004,23-000 ,
' . ,V14:0
VZ. WZ 07
AWr DtPURLIC PLACE -S -RE, Sir. 701-0W-755-000
S70,40
SU.8-TOT-M , CONST RUC 110NAIND' PLi\N C11 6CK
TOT41", PERMIT FEMS DUE NOW
RECEIPT DATE I By DATE FINALED
INSPECTOR
S43210.70
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade`��
Steel �j-
Roof Deck
ReturnAir
Combustion Air
Exhaust Fans
O.K. to Wrap Z3— 6'
F.A.U.
Framing �Z—/3 6'_
Compressor
Insulation
Vents
'
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath V� -3 -
Drywall - Int. Lath
Final
Final 3�
POOLS-- SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gab Test
Electric Final
Waste Lines 9. /y 9 % �$��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral �
Pool Cover
Sewer Connection G
Encapsulation
Gas Piping
Gas Test f 5
Appliances
Final
COMMENTS:
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 (Penn)