0109-259 (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
7141 U
Date �''��'.� Signature of Contractor -f'% 3'•`%,r.;'"�'/..:>
OWNER -BUILDER DECLARATION
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).
() I am exempt under Section B&P.C. for this reason
Date Sionature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury 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'C33C Sad' l RAC.i E 043, Policy No.
(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, I shall forthwith comply with those provisions
Date: j,., - 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 Secti6`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 hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 1 V' 14t�) t,:P" RP.-• - p Date'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
'le) ..7 ' / t . � 5�, ?A197.3
JOB SITE APN
ADDRESS 9.8445 Vq]D .PXlVt''.,�,.N"4.`P' WAY -072—
OWNER CONTRACTOR / DESIGNER / EN (NEER
Ch;N'1.'€.3R',i(' C 1.140 IELL C£!M AIrTr-11 MNl' f CRO�ii'�-:.L CONW. TNTYXI S
1335 SO. "Do i".kR"!'. S'1'E, 02010 1535 so, IV IrMHET, 76,M 1#200
MY BERNAMD190 Qk f124 !(`iF6 SAY MMARIiWO VA 92.4 8
USE OF PERMIT
EM 'NO
Yfill*&Mly ELL
71) . LOT o, AN 5xc. P&F}! n- orms war WICC.UDE BLOCK WALLS,
POOLMA t?'f. DRIVEWAY APPR.C.ACH. i3'C'w PLA14 CHECK PEE REDUCTION
110R. -ISSUANCE OF SAME PLAN TYPE
TRACT C014STRUCTIO14 Z021100 Sir
CrARA.019CARPORT 41,710 Sly
kwT,wi�V
C00r O.a' Ot'?NS'MUMOR
376 , fJ
PLAN CHECK FRE
10,1-000-439-318 39-318
$141.17
MECIVN13X AL FKH1
101-000-421-000
t+"d.,rt.C` RICW,PRE
101.000,420-000
41;0.59
P1uUIMUNO M-1
?C1M1i00-419.000
3149.00
STIZONO MOTION PEE o RMID
101-000-241-000
311.81
LY40 PRE -PAW FM $0,00
J
,
OCT 0 2001 11MUT V= DUE NOW �tl2 J.
t;
CITY OF LA QUINTA
REQEIPT DATE BY D LED /� INSPECTOR
it�ir- f ,l 1. hi� ' V
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
[�
Underground Ducts
Ducts _
Return Air
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
j � 3
fi it—vY
_
.—� _
Combustion Air _
Exhaust Fans
F.A.U.
Compressor
Vents �—
Fireplace P.L.
Grills
Fireplace T.O.
Fans& Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final_
a O—za .`
Final
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
�Q�
g�
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_ _
�O.K.
for Finish Plaster
Sewer Lateral
Sewer Connection
y ��?��
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:A*Final
Utility Notice (Gas) L5 1
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
RougliWiring _
Low Voltage Wiring
Fixtures
_
Main Service
_
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)S—