0202-116 (SFD) (2)- - 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
Firofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
'
Aat1Signature of Contra-fo nzA6,1--
OWNER-BUILDER DECLARATION
d.hereby affirm under penalty of perjury that I am exempt from the Contractor's
�;--license Law for the following reason:
i' ( ) '; 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 Seotion B&P.C. for this reason
Date Signature of Owner
. r
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. .
a( ' ), 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 Policy No. -
STATIK FOND �#a-61-f11MlA4�tti
(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 tha ,if--hshould become
subject to the workers' compensatio rprovisionsedf=Section 3 00 of the Labor
Coote, I hall forthwith comply witf�•`those provisio �s.
�Datefj��� Applicant—_
/��.^
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, 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.
Lcertify 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 authofize representatives of this City to enter upon
the above-mentioned properly for inspeotion purores'."
Signature (Owner/Agenf)�� ••• �� �'r '\ •� Date P '
•,BUILDING -PERMIT PERMIT#
{, N ^�•'r:.
DATE _yt./F VALUATION LOT TRACT
IA"
• ..
JOB SITE APN
ADDRESS 5- x' �i+�. ?� •r� 4 �:0 t i
OWNER CONTRACTOR/DESIGNER/EN INFER
WIR i"W MZ E AK LI!"R 91WMa '. 4
1860 CHICAGO AWY, St ME, 7
EVEW1: E CA 92507 , PaVERSIMI R CA. 9.2':508
(9u9)►85.00.34 � C:ERIA1, 6123
USE OF PERMIT
lWOLU :I?IML1C 3 3MW LING r
SM -PERIVIIT I1L1.,&S.AtC,IT XNC:LUDE 3I..C3C 9'WAL4 POOL. OR. DRIVEWAY 1
APPROACH, flA CODE0.75 % DISI ".O'iRt`a OF PLAN CfH; ;3S IAB. FOR,
MU)i A i1Ti..Lr ISS'UANC E OFE. PLA11 TYPE, ,
r
TRACTCONSTRUCTION ,, w.G6 sy
VIORCMI'PATIO 96. M .5V
(I'A A-0ZICARPf)Ii.?'. r-- 9"95,66 SF - - - - -
5 Fr. WOOD FENCE A
ESTE",= i, ou..r01r Ci(;J: rRUC110H 93 76,20
PKRNZC VER SUMMARY'
CONISTK 101 FEE 101-000-41 iC«WQ
PIAN CHECK IEEE 101-QiRi!•-439-318 SIV.62
fid& DEPOSIT 101 -OW -439-318 429{3.1)4
MECHAN'(C'Al. FL09 101-000-421-000 $6150
R ICCTIUC.A.1wFPW 1.01.000420-000 MOM
MUdefllING FEE 101-000.4 Z 34t 0-
S'I'ROW0 .W)TION IAV E RESID 101.000441.000 0.46
C3 tlal'IM0 FE 101 -ON -423-000
DWE:I.APEktWR.V`d .E3`6bs
I>i7 CISI� PI, I i :1 10Y1•000 4.41^;3 $lad.00
4250.00
#�1LY11: , C`r'F' S; DINS, NC3t
RECEIPT DATE �/'/: BYl� DATEFINA'LIEDO j� INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
77-
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
toe—,
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S- 30 • 07, .
Drywall - Int. Lath
S-r2�- G 2 G, �-
Final
Final DIi
BLOCKWALL A PROVALS
steel
POOLS - SPAS
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
Heater Final
Water Piping
_
!J
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
3�2�..f�L y�
Pool Cover
Encapsulation
Gas Piping
Gas Test
;'L.L_ 22
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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
Final
Utility Notice (Perm) y G a
COMMENTS: