0106-203 (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
A
Mme^
Date a i`'%_ Signature of Contractor'Mw �*
OWNER -BUILDER DECLARATIONAl.
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
1permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No..
(This section need not be completed if the permit valuation is for $100.00 or less).
—(-)-I-certify-that-i n -the -pe rformance-of-the-work-for-which-this-pe rm it -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 pro ,S,,io,�n,,p.
."Date: � � 6.�'I APPI c nt -"�_. /: �.,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to,$100,000, in
addition to the cost of compensation, damages as provided for in`Section 3706
of the Labor'Code, interest and attorney's fees.
IMPORTANT Application is he made to the Director of Building and Safety
for •apermit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each Person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, iridemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application -becomes null and void if
work is not commenced within 180 days from date of issuance cf such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have+ read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above mentioned property for inspection purposes. % 'iY
• ,Si nature (Owner/Xent) ' Date
- BUILDINGPERMIT PERMIT#
`
DATE VALUATION LOT` TRACT
//�
k,
(. 1 1 !?'{.r�l.�� �it1 � 28960
JOB SITE
ADDRESS gyp( y�Ay�
APN '
OWNER^
CONTRACTOR / DESIGNER / EN INFER . _
C!Ertm . L��Cr
~rs X HOMW
7,180 W&V)Low anu, sum. 150
2260VIAi]MOW CMICUE, 8-UrM. Tan
CA, 91720
CORONA ' CA 91120
(909)709-400 CM0 5761
USE OF P//ERWypMIIryTn
M7JJ4\iCJ 8 iF'•iOW:�$ ��'r'r�W,«�-0.di�.��F�
;iYP > LLAT 40 PLAN aCR PERMIT OGMS NOT .Ep1G1 11139 M{1C1*•WA)XA
PCiOU'�;, OR DRNEW Y APPROACH
C'11oTG m, CONSTPit7C710ki 2,973,00 qac
FO.RC3•fIPATTO 300.00 SF
0AXAMCA1ft, ORT 634.00 Sl$
' nmiumm COgr or collwSTRUIr. MR
240;346
�'�p
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.�+i�ASiL2A4�4�t,6.12vY�¢-P..�� T-'lf-a-a_lfct�`-'°2-7-su-5li.+tl
PL:,AN 'CL•iWX M, 101-00043941M $83tt.3�
I1 ECHANIC ) - PU 1011MQ-421-000 $111,30
Ed.. ''3'staC,AL FEE 1Oa�si{�0 a2G-Oa0 �18s.SfL
PidUMBI;NO 1; F '101-000,419-000 00,419.000 MOM
t@U'NO MOTIOn FZE - i2 ID 101- Y00-241-000
op..Wno 101.00'0.4 123 -000 $20,00
INYIT.t�.STl3UCsU1$.E° I, 225.000.4.43-342 x1,90 110
liWr IN PUVLIC PLACES - T DIE 701-000«255.000
P
SUB -TO, ` J 1Fa Q014M, 1•OTION AND PLAN G`•1 WP -X
• •,f M.65
;`•. � t :IMS 1"`Fc1 -PAIDF M
$0.00
i
niRR
*WfAL
FLqMT FEES DUE' NOW
'RECEIPT
RECEIPT
DATE % -BY��
D JA1A
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings —
Slab Grade
Steel
Underground Ducts
Ducts
Return Air
Combustion Air
Roof Deck LExhaust
O.K. to Wrap . _y _ _
Framing 8 ` Z
Fans ✓
F.A.U. _ - -
Compressor
Insulation
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines /
Party Wall Firewall
Exterior Lath
O 9L -
Drywall - Int. Lath
--
Final
BLOCKWALL AF ROVALS
nal _ -Ci'✓ — —
POOL ' - SPAS
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 1��6 SGL -
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _
Sewer ConnectiondL
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances =�
Final
COMMENTS::
on
Final
Utility Notice (Gas)
ELECTRICA P ROYALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures¢
Main Service / _
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors ./
Temp. Use of Power Q
Final
Utility Notice (Perm) - — -