0310-151 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
w H Mit, 7131/114
LLI r i
oZ r— Date ' Signature of Contractor
CD O R
J U C:) OWNER -BUILDER DECLARATION
W LU r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
fn License Law for the following reason:
Z_ ( ) 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).
C'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O�
CL Z WORKER'S COMPENSATION DECLARATION
C Cr I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q L) ( ) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
d 0 H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier VTAA9R3!"' Policy No.
Cb 5
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
1 of the Labor Code, interest and attorney's fees.
4 IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE ` VALUMIO i' 912400M, LOT TRACT
f �l
1
JOB
ADDRESS 77-7W CALLS (.� aN
APN
OWNER
CONTRACTOR/ DESIGNER/ EN ]NEER
P'UW)M Mx3Mf': AWC t2Xf"412i NC.
BRAJX7JAA)W NC
P.O. BOX 114
Po 'plox 11) 7
4kQUnq CA 92233
1..11I.QUIM-A CA W,25,:
(70))4W-5}.22 ("IBLO
USE OF PERMIT
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PLAN C1M'-X Ml 14? _04X1.4:9.318 s$'P."5
CONS ► RETt:.Irlo?i PER WI -000-418-000 81950
M1C14,ANif `.4L 171W. -. Iti +Dt 10V1 -000.4'_1.000 434.00
F' ►U •- Mil, 101-000-4120-wo $45.00
PVJMHI ,,�1.34%--POOL 101-000-419•40f? MOO
CM,4�tMIMI AND Ff CI11��C
20 K03 Tl:YT L PNWIT IM uUP.IT0W
I
)UC1TA
DEPT.
RECEIPT
DATE
BY / ,
DA7E F114ALED
INSPE
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
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
a
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Vater Piping
Plumbing Final
P;umbing Top Out
Equipment. Enclosure
Shower Pans
O.K. for Finish Plaster
$drover Lateral
Pool Cover
Sewer Connection
Encapsulation
d
Gas Piping
Gas Test
Appliances
Final
. Q
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:
6�4EET INDEX
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LA QUINTA, CA e2253
i PROJECT AD
""' �,�� TOE
t0' U/L�a I n .
OCCLIPANCY
6IWsLE WILY
, TYPE NON -RATED
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1 lr514 SQ.FT.
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COVER, -D A 1 1�1+ SST
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TOTAL 1 STRUCTURE2;2( SCE.FT s
I TOTAL SITElzm
4,814 5O
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TOTAL LOT COVERAGE
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