0109-275 (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
794195 B `► /01
Date r" a.: Signature of Contractor
c / Y 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:
( ) I, as owner of the property, or my employee's'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&RC. 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 W,.kDD, Y j?.v' OL& 994;3. Policy No. NWC` .A40W 3
(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 y "-r z
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 Ouinta, 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)f�_ - �� + Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0109-2_11S TRACT
'. ; 9,M4.30 49 2415WI-3
JOB ITE '0 - Y APN
ADDRESS f 1,M. )EP=W1:N IW AY 04-072-M
OWNER CONTRACTOR / DESIGNER / ENGINEER
Jrf
1,13 5 so, "W map. -r, UM 11200 1535 SO,'D" SURELI'TJ 8,112- 4200
SM ROWARi7WO CA 92408 S AW BERNMDINO CSA 91,.09
009)381-6007 C K.3P 2120
USE OF PERMIT
SPO WT 49, 'KAN %k:,. PLUZMIT n,OIYS NOT INCLUDE 1' LOCK W.A1.1a
POOIAI9AOR DW1[?5WAY.Ai'PROACH. 755%P1,AH 01Pt':K FE, E IEU6CTIO14
FOP. �,WM NCRI, OF SAME P1,AN'1 YPP
TRACT COM FcIXTION
P(31w,fv".Ax'1+0 X740 SF
+; ZMA.OWCARPOPIT 413.0199
CONSTRUCTION PRE 101-000-416,000 VN4,3D
PLl ivi CHN4111K 3 101-000-439-318 $1 U.156
ME " ANI(?A1, nm 101-000-421-000 SA 50
PLUMnumo kE 101-000419-000 SIVA
1<; PCtf3?1dt:'l MOT1014 PRE -' ' 1.13 101-000-241-000
d,9RADI3vO FFM 141.000-423.000 524,n�
rD%9ta� .�ii►'SdL2HAPACT F24 $3,907.00
:w"YOTAL G'O9tiF`�I"!.'RI M"; TOR AlsTO IYLAIN CMCK $2,94.1,79
' `1 P112 PAID F ti, Or7
YAWMIF LES VUE, NOW =947,79
- 4
RECEIPTA/ DATrEBY f DAT ALED INSPECTOR
'.f' baa _ Y• ✓ ..� , ~
INSPECTIOO N RE�:�RD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
!!1 3G- Q (
Underground Ducts
_
Forms & Footings
Slab Grade
C L tj
Gl - G
Ducts
Return Air
Steel
Roof Deck �j f� r J
,� _ �_�J _
Combustion Air
Exhaust Fans
O.K. to Wrap
Framing
57<Z _
— �/ •- �S
F.A.U.
Compressor
Insulation
Fireplace P.L.
Fireplace T.O.
_ _ �—
41,
Vents
Grills
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
_
—�?o
Final,
POOLS - SPAS
�S
UL OCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
--Z
_
Underground Plbg. Test
Real
Gas Piping
Pd.41J6`U�Jf 1MG APPROVALS
Gas Test
Electric Final
Waste Lines
�_• ��� p `G�j�
Heater Final
Water Piping
Ti
Plumbing Final
Plumbing Top Out
_ly
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Svaw Connection
% — ` -
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
c
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -o'er
Utility Notice (Perm) --