0109-273 (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
714188�aar�
Date .' Signature of Contractor r
'OV
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 jCg,1,,1t77g?�11+f1T��•INS. 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:.Applicant
14,-x ZPY
Warning: Failure.(o secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
'1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this app:icaton agrees to, & shall, indemnify
& hold harmless the City.of La Quinta, its officers, agents and employees.
2. Any .permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or, cessation of work for 180 days will subject permit to cancellation. -
I certify that I have read this application and state that the above info"mation is
correct. I agree to comply with all City; and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. ,
Signature (Owner/Agenty /12, 411"-, Date /
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ��^ TRACT
47 243W-3
JOBA `"
APN
(
ADDRESS mv
umswl Y
♦k�Q % - i�r
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I:51�4i 30, "3)'" z'1.E J & y r.;<. #200
1535 so, °ry mmm, 9".d' . Ingo
lgJQ4) 0WARD1U%0 CA 92.408
S.1a.3 BLMNARDDINO C A 99.. O8
(909)361.60107 CP 2120
USE OF PERMIT
Sita .1,,0 47, PLAN 3X'Q. P99MIT 001�::t NOT ML".LU VE if91,0CK
,€A_i.%'P'CK).t1S A011DR1V11-WA"�APPicE�ACK 5%,PLA4 ME=RZ
'a •1?LS:I'TO14 FO; ai .1SzSTiY�1h'.C:y:+v%1 SAMEP14AkS Tfirbl;
31?
TPAC T C'ONSTRUCj` ION 2,023.00 9
POR HfPA; 0 11.00 SP
CiA1A. MIu.dR1•°ORT 4.17.00 OF
ZR'MEATED *a: MT OF CWd.Y$Yd4X84±'MO8`[
1. up`Pnago '
PERM YKE,'NUMMARY
Ct>Na3'£1 IC:TION FEE 1014)0-410-000 6.0
F°s..,Pj3CHECK pa 101.-00 439.316 $147.17
MEMLIVB'iC<AL PEE 101-000-4-21-000 $60,09
L3 7.r'�:'T TICAL FE
PLUM, DING 1~ME $140,00
51'll.F; NQ MOTION 9s`R8 • RESW 101-000.241-000
(DRA.MOM& 1€1.000-423.000 31 0.00
3 .v,,V E.fr31;� R IMPACT FW �1,9QP.00
Mid=1WAL COMin :D•CrI00 AW3 PLM3 OHMIC
$3,127.56
LW3 PMPAID M-3119
$0100
1`11XM'F1MSDW NOW
13,127.56
cr 1 �`
.; C
RECEIPT r:� DATE X
BY
DAT ALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z1j=30— O(1
Underground Ducts
Forms & Footings
Slab Grade
_
1ReturnP9_
Ducts
Return Air
%_2 -B-
=
%tel ji - 2 c
Steel _
Roof Deck ���
_
/� 06 =�J/ �r'j
Combustion Air
Exhaust Fans
O.K. to Wrap,_� �- �'
Framing e�q" S
Insulation
F.A.U.-
Compressor
Ventsj
_
,2 �j'�
_ 1
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath_®y
Drywall -'Int. Lath
Final
Final
��ji-
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
=��dZ�
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/�-� 7`
Encapsulation
Gas Piping
7C9
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
7
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
z1141,
Low Voltage Wiring
Fixtures
_
-
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
`
- -
,Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Z/ Z