0306-322 (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
Date t•"4 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 yyvith wages as their sole
compensation, will do the work, and the structure isAot 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 ?vA7'TC3NAL 11141(W F Policy No. 700119
(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, Pshall%forthwith comply with those provisions.
Date:T 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 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 employe -L6§-.
2. Any permit issued as a result of this application becomes null a4'Void if
work is not commenced within 180 days from date of issuance of�isuch
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 informaticI nlis
correct. I agree to comply wits, -all City, and State laws relating to the bill ilding4
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propert',,for inspection purposes.
Signature&Ow er/Agent) Date—
.., e
ate
BUILDING PERMIT PERMIT#
DATE F VALUATION $136jtW.j.00 LOT j ;f-; TRACT
'JOB SITE ADDRESS 60.245 aYir�i5 71F.CA!� M �.�.iT`t.X
APN �L2°101 -'
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MWA LA t71.'1R1''1'4;, LlX
1i.F. &17101
LAQ'C b 1'A CA 9V53
1.ttf�y�,eiS��7.TYa,[�i'1F.App CA, 'Y28tt5?
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USE OF PERMIT
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ougrom. coNS`PirOf:ro.,i 1,33,617.=a
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CON i'9i1LpJ iW? M, 101.000-418-GWO 1+769,00
rrx.ra+N CHE"01S 1f .R 101--MI-439-318 $5;A, 114,
M RANI Ah €`:Zh 101.000,421,000 too.4
h I,C.IMBTNO FRE 10111-00.41 `rJ.01" 4118144
,
STRONG MOTION FEE 1116 -000-21.000 $173,6'3
ORMIIN I WWI
is !'E1 G°Ft;1' IMPACT fF"iE S$2,4Ui.eU
IYU PR .ADKD IT.1'.k
,fit `: K�
TOTAL F:E:.1 MIT F1 EN DI Mi. NOW
84,L9 `Ko
V
RECEIPT
DATE r
BY
D
SPErOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Bond Beam
Forms & Footings
Slab Grade
Steel
Roof Deck
Final
O.K. to Wrap
PLUMBING APPROVALS
Framing
Waste Lines ..// -
Insulation
Water Piping
Fireplace P.L.
Plumbing Top Out
Fireplace T.O.
Shower Pans
Party Wall Insulation
Sewer Lateral
Party Wall Firewall
Sewer Connection —
Exterior Lath
Gas Piolno
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Retum Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
rinai —
BLOCKWALL APPROVALb
POOLS - SPAS
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 Piolno
Y •"
Notice (Gas)
ELECTRICAL APPROVALS
Power Pole
v.. up g v v ga Is,a
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power _
Notice
COMMENTS: