0109-261 (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 # Lic. Class Exp. Date
Date � � �.'`7 Signature of Contractor ✓�^r� � w��, y Y , ` .,� �,.
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 & Professionals
Code). I+
( ) 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 C?iJ:;%9d1 ED3�3, Policy No, ybEIC.`-544G�6 43
(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
subject to the workers'. compensation provisions of Section 3700 of the Labor
Code, l 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
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
& holdharmless 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.
r�
Signature (Owner/Agent)—d f,' a Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0109-2'61 TRACT
31 24197.3
JOB SIT9 APN
ADDRESS WAS' r€�4 t1'7 a AEft
OWNERCONTRACTOR
// DESIGNER /ENGINEER
IyyfNIVjjY,CIRMUL 4ONiW�r", G�yYrupa,VYLg.' ry/$9Vdams
1535 50" `1" Fr IT, UM 4200 1535 30.'I'D"S Im"T, YI`E::. 02003
i :l�i°d %.�.fiV�i CrIk .924 t3 SAN .A .�tut.�.M1® CA 92408
(P09)381.60m MIN, 2,120
USE OF PERMIT
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TRACT CC)1u`S',f'1`UCT10N 1,80.00 3.14'
PORCIMPATIO
11.00 Sy
C;,ARAWS CARPORT
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1�EVE11'➢,i� PRIt IMPACT KY.'
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JEW PTMPATD 1Y 1 4750.00
YEM DUE NOW
OCT 0 5 2000
C@Tl1 OF LA C,!l11W A
FIt2ARCD P -21 -
RECEIPT By DT /, INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings (� ` N
Ducts
Return Air
p� moo_ vi
Slab Grade fid_ j_ 6r
Steel
Roof Deck
_
Combustion Air
Exhaust Fans
O.K. to Wrap
,� . /7 _ p
F.A.U.
_
Framing
e% eyp_ )!
Compressor
Vents
V% 6
Insulation ��
Fireplace P.L.
Fireplace T.O.
_ _
��
Grills
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final /= a
BLOCKWALL APPROVALS
Final
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 1p/�� % 1
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Water Piping / G'
Plumbing Top Out p/ O¢C?qS
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_ 2 q��
Encapsulation
Gas Piping
Gas Test
�.
Appliances
s
Final
COMMENTS:
Final
Utility Notice (Gas) 7
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
_
Fixtures
Main Service _
Sub Panels (71
Exterior Receptacles t�
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)