9905-245 (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
637252' 0T 2I20f
b •✓
IA e?_J Signature of Contractor�9�._
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 Policy No.
te:JYras :1NSS. CO" QIF e I"I.'f, 45925?
(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 wsl ns.
ate: 14 ` JS 1 Applicant ►4
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for-irIspection purpos s.
ig
nature (Owner/Agent) ` _ Date
BUILDING PERMIT PERM'�11��
DATES/ �l VALUATION( l]1$k�#o{�j� LOT 3A TRACTI C►1•-i
JOB SITE
ADDRESS 47-540 NRA11fiR4Ea1 R Y $ YEL'r 0.
APN 649-030-0,20
OWNER
CONTRACTOR/DESIGNER/ENGINEER
r pp+ rr r i<rCC n� .�C*"I"nrrI At rrta, }u!( torr jT� ^ c
1-rL't. I,rSlV I.l 1101.4-1 •J.1 •./;`1-Aca- M1/Ai�l�,'.i. l il,'.i. /Ivtl
7f�r (� �1 �}r+ � ra 1f �.e;ri7'1�a�Pr•r c v.�s•r.-PIU�CTI Gni
l� V '+.f.f�. {_:1,,LU, l ,L•.A,. e1t/J � l•i ��'l iJ ./. `'tV V i l��l`t
-.R.I
3 PARK PLAZA; SUl fC 400
§ P.ARK PI AZA, SUITE 40
IRVINE CA. 92614
11M.N E f :A 92614
(949)251-6100. C133_.#1 V72,
USE OF PERMIT
SINOLE RAWLY kf .WE gid:,. WO
5 43 -'K.j 211 2A LOT 34 - l�.Ei.�f. T, .i707h9 .NOT' INC U E LOC. ��1.1.a
QK lltn?iv, ..K.AN CMi lK k't>kt`i10N 0F.176 -1i Ii ULCM) 73".:0 FORL MUU11.4?I
iSSU.AN f OF' SAtr E.f%1.•AN'FYIP9
'rR A,LM G'eaiti,°-a',1' V 010N 1/914.00 S
PORC'7rti ATI TO 120:001%
GARACf'r CARPOltr 4 ;3,00 SF
EST UMTED 11° C€�iYSa i ON
CO.N:€'rRuc'i'fcyNY,,EE 21014)00-418-000 5,692.00
¢L&N rWCK.VTF 1014X00.439-318 x1/4,6,Y)
ivi CHANICA,iJ nw 101400421-000 $66-50
i~T,13t:'l'i<,ICAL FUC 10.1-000420-0010
PLUMBING FEE 1014)00-4.19-000
;KKRONQ MOTION• E'f 1; - RBSTO 1.01-000-241-000
C31tA19R40 rEB 1,01-0004a3-000 $210.00
iTlFRMITRUO`1'URE FR 225-000-443-342 S'45:5 1,43
A 14 IN PUBLIC PLAM -) HS1•T: 701-W-255-000 S?x.48
.r a
, I (1 'T{ i 1(�.tit�IS 21'1x±.iC"1• i)I°1.AI n 1'I N ?,);( X
3,gL�j�RA:ih
c
e . ` 4. LI, r l A YY'1 FJ1
10.00
;., JUN p 199 � �:1 �► � ��• >; � : � .� ° ��
$3,t mm
RECEIPT _
DATE
By.
DATE FINALED
INSPECTOR
F.•
Il
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
f
Exhaust Fans
O.K. to Wrap
o - !/ - T
F.A.U.
Framing
Compressor
Insulation
v _ S. $7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
Final:
Final
BLOCKWALL APPROVALS
POOLS - 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 LinesHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_ �j ,T
Encapsulation
Gas Piping
Gas Test
& _!r- ',-r 57
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 ,2
Utility Notice (Perm).g®kv
COMMENTS: