0305-254 (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 r Exp. Date
640934 13 06 3.onk
Date.' _- Signature of Contracforf,� }� -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that, l am exempt from the Contractor's
License Law for the following reason:
as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is Pot intended or offered.for
sale (Sec. 7044, Business & Professionals Code).,
( ) I, as owner of th'e 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.
(+a�j 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 . 3+14'1 XON IAL, Utq ON F Policy No. 1053"
(This section need not be completed if the permit valuation is for $100.00 or less):
O .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' corn pen sation,provisions oeSection 3700 of the Labor.
Code, I shall forthwith comply with•t}ose'provisions "
Date:'a - 1 " Applicand-
.,-
'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- mentionedproperty for inspection purposes.
Signature (Owfier/A • ent)N+r { M Date
PERMIT #
BUILDING: PERMIT
DATE VALUATION�e7 LOT,; TRACTJOB
SITE'
ADDRESS ]� � � �t'sad.Fdr ate:
APN
764-270-01
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M HOWS,FORACInVE ADULTS
51X,A H03 0_8
60.31.1 IT_CW0Y PAR_- N.WA
81460 AVENM 6
LA qubrrfi, CA 92253
TFW.RMAI,
CA M83
(909)a.�. _8996
C L# 006
USE OF PERMIT
301N(fl:E FAMILY DDWE1. NG
S1?D • LOT 73 PLAN 551513. PERMIT DOES WOT INCLUDE BLOCK
WAL99 i'004 04PA OR Dt rVFW.a Y APPROACH
L
CUSTOM M, ?�I5r3,Q(1 SP
POP.CWPATIty i7d:i4p S1t'
GA'RAQWQMVOW-E 8F,
XfV' M4.fATRJ) CIPS. !' OF C0XSM174'Y7IDYr1
CONSTRUCTION -FEE .101-000-41,8.000
PIAN CHECK FE9 101-000-439-319. VAo.79 '
hltWHANICA,I.FER- 101-000421!113W 08150
FOXCTRICAt., YFX 101-000-420-000 x1213 -V
PLUMBING FEE
STRO'N 3 It a ION : FEE,- SID .10.1-000-.241-000.
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.101.000.423.000 '�(I1?S7 o
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RECEIPT
DATE
BY
D FININ
ECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs '
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
_ 3/ . _
Return Air
Steel
7 _ — 3J&6
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
_,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
12 4e
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 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
_g / --,3
Encapsulation
Gas Piping
Gas Test
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: