9905-242 (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
Dater 104/ d Signature of Contractor �, , `,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: v
( ) 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).
O 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.
00 1 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.
LR6: T At.. INS, Wt Or :t 'PTC 45 237
(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.
¢ate: Applicant °��• '
j/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.inspection purposes.
ignature (Owner/Agent) Date"' +
BUILDING PERMIT PERMIT# f
-
f
DATE(- �f VALUATION S,12-4,33(ljo LOT 3� TRACT n6ol«'I
JOB SITE
ADDRESS 47 -US SILIVlEiRTHE V ".s+TRE !
OWNER
�I�i:y 1 (7 iyy 1 At }�/��d��f ryS 1�7
CAIMI i,; 1-rd.°i3 ,ti v.�illA:.ii�R�t'13. i.�.J.[i'J, yud.4i iit, p.Yl L' c;Yy
SCO/NT/R•.ACTO(R/D�EySIICG+NtE)R9�/tE�NGINE2�E1�R# Af / r1t,1{ quit f Y
F iVty, i.F.�4� i:•irl..�>:+ t�U.Y iDf.ti-'6 "•�(:'61:. l...l./,I.N w��{. [\i /'•u .071.N
i PARK PLAZA, KIME 4W
5 PARK PLAZA, }'ii.TfeE 400
lR'+lLt�' CA 9261 it
IRVINE CA. 92614
{9411)1251.6100 Ci3sr#T N72
USE OF PERMIT
Sk!""d�l'LP-.%ANit1,"'f' i'1.if1+"E,LLING
UR,'P�1. 2'.L.:�N G�"�G'}% iac.)w'[',i()ty C� �'P�.kt7s"I)tl'C;f� •7��✓u FCjR itrLiJt.1 }�+}
TRACT CONSTRUCT VION 2097.00 SF
PORCt}7PA'! IO 124.00 S:P
G.0AQEJC.,tI}010X1 SF
r
EXT INIM , D CMIT OF CONSTIZUCT Ria, d
124,3330
D?RANIf. FEE SETWIMAD2f
001SIST'Rtifr FIONFER 101-000-418-000 $7 1:t3:►
T,N r;N?�.; T4s 01.1••41941 S;
;������:�a�.€r,�,.r�s�. ,•�.°cath-��-� ��.�e
IRA-; rfWAL. F 101-000420-M
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Tf[,
"n?'(7WO !,A1„•t ifYN ��.':) — e4k'ri�f,f,�!
GRADING FE, 6 101 -OW -413-000 X20:
1191.11i.t1ll TRU'CTIUM. rw 223-{}00443-342 $2.740.45
ART IN }AM;aG PL ikCES - RES1.0 704 000-255. 51 16034
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h
S -` CYt'AL COMMA”,710N AND PJ A J CHEC-K,
", ,090,42
L, S D",i T l'��ll ) a
X0.00
1999,170TAL PERMIT FEESDUE OW
$4,090.4.
RECEIPTDATE
j:'= ••:
t.
BY wj
DATE FINALED
INSPECTOR
t :r
INSPECTION RECORD
OPERATION
=DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_�. , / c
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
4.F.A.U.
FramingB
- — —
Compressor
Insulation
$`
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
08
Final
Final k
BLOCKWALL APPROVALS
Steel POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- T -
Encapsulation
Gas Piping
Gas Test
—/S—
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)
COMMENTS: