0109-257 (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 Divisir n 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7)41108 1
Date '' Signature of Contractor
F 1 _
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. are:
Carrier E5C5 A7 %datf $k f X Tk$'S. Policy No.N.� WVC#•,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, I shall forthwith comply with those provisions
M . ,r
Date: *., r. _'. it • / Applicant—
Warning:
pplicant 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
& 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/Ageni)"V P k/ # t} � �' - "Date A), f
BUILDING PERMIT PERMIT#
DATE VALUATION LOT '"'°� TRACT
JOB SITE
APN •.
ADDRESS�?1JVJ�(,X WAy
S-?2ub3h3
OWNER
CONTRACTOR / DESIGNER / ENGINEER
15":::1% 30, T" IMM, ', ;ifii?.#200
1535 9"'), "Dm STREET; 2T, L 0200
SAN 13,R AaiDWO CA 92,408
rte&EMAEUM0 C.A. 92,108
( Y481-6007 CSLX 21201
USE OF PERMIT
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r.'-10O,t��i,�'�.u".0 O.�i��2�.fi''3` i�.�.°.�kPPROy+..ACOHr 1150,; PLAN CKECK NE �.y.'"��I�'UCTION
N'f R 12SL A-VICZ OF 'SAhSE PLAN TYPZ
'TRACT CONSTRUCTION 111W.00 SF
91.00 Sir
+t_Jima Y� a x t P� Ns�ro.t i. vy
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CONSTRUCTION UCTION gi ,r 101 400641841100 S010
:MEM' 101-000.4:39-313 $136.02
f C HAINiIC NL 1ZE 101R0004,21.00Te 560.00
F,.:L~7.t::`fRH!AL 1i`ZE 103 -000-42.0-000 $1:17.24
�'Ga,IM:832��>r3 �I;aI7 101�f,3Cit'�4]yu �13�.5�
S`Y'RUX10 WrIC3'NF It OE - FZ51ID 101-000-241-000
ORADWOITZ 101-000-422400 120.00
DFIV�I,�i P&"_ IMPACT YZE
%�v� Ir1"d-3i� Jp.�iL�► I?i�.A�x3
�3, Chi
YMUTFUS, DUE now
3,034,07
OCT 0 200 1
CFS OF LA Q It4TA
RECEIPTC'Y
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DATE` ` u
By to
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INSPECTOR
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7
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
.BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
`(J- Zell
Underground Ducts
Forms & Footings
Ducts
�7
Slab Grade
Return Air
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
f�/ ��3�=� %S
>x —�� �> ,��
�_� ? .-p� �
a/ pa 02
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
(r/IT
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/- /G -Icp z �s
Final
ZC9
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
_
Waste Lines p _
Water Piping i
Gas Test
Electric Final
Heater Final
Plumbing
Plumbing Final
Plumbing Top Out
Equipment Enclosure
O.K for Finish Plaster
Shower Pans
Sewer Lateral
Sewer Connection
Ll/.,? -�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
y,¢zvs�Woo
Final s -Zd
Utility Notice (Gas)
ELECTRICAL APPROVALS
APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring ,'� 277
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)