0109-272 (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
pr..�
Date `;' .� Signature of Contractor.,r; yf� 1�� .�1 ! ^�Y�f / A
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 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.iare:
Carrier OVLT>R�j IN,%Policy No. N YC -54063-03
(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 provlslons.� _
Date- % Applicant" - ,i iA r G!'!"4.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
I
1. Each.person upon whose behalf this application is made & each person at,
whose request and for whose benefit work is performed under or pursuant to
any,permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and state that the above information'is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
,the above-mentioned property for inspection purposes. k
Signature (Owner/Agent)~:1 <'i[. -"t . Date
1.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT -27 TRACT
SIOV70.60 46 24197-3
JOB SITE
ADDRESS 114!F1Y
APN
(i W0721_04%
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i+tel "Ci;6`fn Y M01MLL COMM'MTf,`E-119
C:3 .Ad'i"URY C.9RO'iTiTf+'.i L (1*0M R'LZlUTM1
1.3'.45 SO, TP ITrIP 'ra U:C, 0.7-00
1535 010: T` YrREX ', ,7,59 07,00
S" FAMMp"'No (,'A 92409
&W BEUTARDINO CA 92408
(909)s s'3 -a]# l 031191 2120
USE OF PERMIT
MNOx lz��,+41,'l i7iJFt3
VD, , 5I 7T46, t?t.t9N :3aR.E'm"br. F�llttR�F> "F° i�t3F� 1+f�1 C Tk1d:i.lt�Fv s"lE £�%F.
REDUCTION ION R ISSUAN EP OF SAI€ PIJ.�N'fYPF.,
!~ORCHIPA'TIO 91.0 8?
0ARAGVCA3%,i'ORT 41�.00 9F
1115 .$�.rXD COST Off' C.%�, 31MILIS�.�OR
1031070.60
���j�ry'��,yy��,�yyp�t,{ j4 '9J�� Q',,
RY
CONSTRUCT] .01.4 FEIE, 101-000,418-000 $653M.
,PLAN CHECK FEE $136.02
I���T4yMHAN7y.Y3�p°��.Yp, T�qE. 101-E�°«li0.421-CYN) $60.00
1?bJ91+1�'i t. d'U4.rAt, C' hG�1P.. 101-000-420-000 $1 I?.24
PI.1MMOFEE 101-000419v00 31,30.00
pp��tyg,yy0y,Cj
0q`=1�0J0D0-44d1-O6f!�
101 O�IN.itV
n
BUS -=CAL C:OMMUCn, kY � N10 PIAN, CI31?`L"IK
$3,034,01
' 3TA :ETS DUE NOW
_07
C9dY OF L�° °,W�► �'
Al
RECEIPT
DATE
BY ' ;
�DA`T -2 ON �'j
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab GradeY�
��
_
Underground Ducts
Ducts
ReturnAir
Steel
Combustion Air
Roof Deck /JR
_
�,� !?6 d /
Exhaust Fans
O.K. to Wrap
Framing
/
F.A.U.
Compressor
_
Insulation
Vents
Grills
_
I i
—�
-
Fireplace P.L. I
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final���
POOLS - SPAS
B'LOCKWALL
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
�U'2 3_O/
- .��
Heater Final
Plumbing Final
Plumbing Top Out
/—ff�-,�,
Equipment Enclosure
Shower Pans
/
O.K. for Finish Plaster
Pool Cover
Encapsulation
Sewer Lateral /
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
f
Alk
Final
Utility Notice (Gas) • ��Gl
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring L1
Low. Voltage Wiring
Fixtures
Main Service
_
Sub Panels
Exterior. Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _2d -
Utility Notice (Perm)