9812-123 (SFD)LICENSED CONTRACTOR DECLARATION �.
I hereby affirm under penalty of perjury that I am licensed unde�,.provisions of
Chapter 9 (commencing with Section 7000) of Division 31of the•Business and
Professionals Code, and my License is -in full force and effect.
License #- ' �LLic. Class' Exp. Date' 1
U 5 13 i 0
i?
Date 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:
( ) 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:
( ) 1 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..
006 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.
_ A=l FUND 035-98-4.330
(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 pro 'sions of Section 3700 of the Labor
Code, -1 sh 11 fortF With comply with thos provisiSns.
Date:%7 r� Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,• in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person 41
at
whose request and for whose benefit work is performed under or pursuant�,to;'
any permit issued as a result of this applicaton agrees to, & shall, indemnif '1
& hold harmless the City of La, Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null -and void if
work is not commenced within 180 days from date' of issuance 'of such
permit,; or cessation of work for 180 days will subject permit to cancellation.
I certify that I have-read.this application, and -state that the above information is
correct.'l agree to comply with all City, and State laws relating to the building
construction; and hereby authorize. representatives of this City to enter upon
the/above-mentioned property for iinspection pur/pooses
*'Si nature (Owner/A ent) ! ''t Date /J l,,.l o w- t
PERMIT # -
BUILDING PERMIT
9�x:
DATE % VALUATION �D�r�Jp%4iii�`4 LOT 16 TRACT 28797
JOB SITE . i9-330'$�)�Z�` NX%
ADDRESS
APN y69-460-(6117
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RYT rl0&4..ES-U C- - -
WT .N�J.1:,fi1' 41IN •'S, PITC.
�'O BOX S10
1:425 E. UN1V:ERSOAr t)1�. VE
LA QLANT.A. CA 92253
J'Et ErNIX A7 83034
(6(Y2)257-16_% C81.11 4990
USE OF PERMIT"
�}y jn � n }9 { ` ���J���y 7 /�((
Si'N•ULE l,CLi,lO]J lr.{J ��.l.lLL.i. G
LOT 16, PLAN 3130. SFD - PIMA MIT i MES NOT INCLUDE FLOCK �?►//SUS,
UIt 2fiG[�1,.
C(1SITOM CO'N: IMUC Ti ION 2.533.00 S
,
laG.itG17�F>A' 3C1 330:110 S -F
`OA1tAG3U<,e3FtP<1.121' 578.00 S1'
EST,INIA :i �I lie' CONST OF C O R7S a 1.R V C ION v
233, iTiv5i)
C'CSN&I'RUCT10t�l �M M 101-000-41€t-1301) U 1+ &50
PI-, N l,!iF>; K FEF 101-00439-31 }i ^W015;,i)i
1L1EsTIAN1C,Ul; FRE, 101-000.1121-000 2105:00
EU1,C�TM.,CAL F ' :101-000-420-000 WS 22
-F;w 1•�IL3.i-[d(..17X 10.1-000-41.9.000
S7 „R.ONO MOTION g -YE, . MEW 1011 -00(? -2 31-000 ' X523.37
GRADING r -101;0010-42.3-000
11�11�:RAS'1 UC'I'E' M i� , 3'w `221-000- W-3421 $5.220.44
Q -
ART IN' PUBLIC PLACES-'RE.31.�i: 701-000-254.000 53�4�37
d -
�3�tc 1a�,lyicy�
r st.Ttx: `TCI � { <?Ns -nits:'? aN, ANT7l:��+��TC.APRE-PAID
LESS E3ALi — !'SLS./ FEES
�otxH_4!
$0.00 ,
_ .
&O AL, P fa.�il�i.1~1''.ir,F;lj. 4.1)11,1, •1� OW
$81066.41
RECEIPT
DATE
BY tvEj�.t
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
2- Q -s
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
4
Exhaust Fans
O.K. to Wrap
F.A.U.
_
Framing
C .
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
Final
2 cr- j
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
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 Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final -Q0
Utility Notice (Gas) : r�
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 !it/
Utility Notice (Perm)