0210-254 (BLCK)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
59156.1 B / 31104
s
Date/W13462 Signature of Contractor � W
OWNER -BUILDER DECVA/RATION.• '>,
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).
( ) 1, 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 ST.A.Tg 1T NI) Policy No. 1661391-01
(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,4 should become
subject to the workers' compensation probes' • ns �f S c Iti. 3700 of the Labor
Code, I sha I fort with comply with those�provio s
Date! ✓� .. Applicant�d'�'''`i-^"
J V(,�.,
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 compensatiol), amages 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 represen atives of this City to enter upon
the above-mentioned property fnsp� . do ppu%peei
Signature (Owner/Agent) `''r Date
BUILDING PERMIT
DATEVALUATION. LOT TRACT
a, f
JOB SITE
ADDRESS 4'7_ J() V. JA AMIFJ
APN
OWNER
CONTRACTOR/DESIGNFN"NFFR
N
igqy4YA COW
. .
itVpwpY& 4\sJSS
CA 927841
'%f>`.;1W CA 92780
Q14)508444-0 CTILA4 44135
USE OF PERMIT
1.
1',s l�',, 6`.0AE2.iWE'R WAI.1,, 35, L. F. 4' CAAWFX IN1sL1, 00TH ORZO ,
�5
3 FT WAIX 5100 111
4 'Fill WAU 35106 LY
WM51V36AI11 a.4i'ib.Y OF COX4113-3-119 Jia -OXO
iJ STNV
CONOTRUCTION FEE 10) X000-419.000 = :; �9f%.v0
r
Y
0
OCT 3 1 �OU2
OF LAQUIN7A W
DEP
FINANCE
CMI3`"J°1 AL CbMWNUM"10..;9 JAM R MI (.IDECK
$19,00
�.` M.11-PAT.1"3 F=9
$0.11£1
�iECEIPT
DATE
BY
DATE NALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
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 — o
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
`Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connectlon
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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 Detecters
Temp. Use of Power
Final -
Utility Notice (Perm)
I, VC 1111, I I . i J I' AA 0W 0 J U A 4 VQ -
R -99.50'
L-20. J2'
0-If42'10'
Ip
CONCRFrE EASE
DRI VEWA Y
,5'
LOT IIJ7
LOT 17J6 5.51
PLAN 10-8 0
LIVING AREA 2,595.0 S. F
GA RA GE AREA = 426.0 S.F.
FF:. 63.40
PAD: 62-90 LOT 1138
BLOCK WAI I
N 7.9 '1 '46- W .86.01'.
(2.) A/C CONDENSER UNITS ON TOP
OF 3' (MIN.) CONCRETE PAD
No. 316-53
Exp. 12/31/2004
SCALE: 1--20'
sl CIO.
OF c
47-070 WA AN77BES
L Av, E- LA OUIN 7A, LA OUIN 7A, CA 92253