0304-023 (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 i Exp. Date
040,9:44 �§ rte, ' j � '� 06/30/2(
Date l �'� y � Signature of Contractors Ifa
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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
Se tion 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 NATION.AI, UNION IT Policy No. 70051110.
a
(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 ,shallforthwith comply with those provisions''
Date:--ik"% �'Ll -2 Applicant 2 1
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. k
IMPORTANT Application is hereby made fo 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.
Signature (Owner/Agent.) Date I '�
BUILDING. PERMIT PFRMTtf
6364-.013 .
�•
DATE �J VALUATION. LOT , _ TRACT
'"��1e�y�� l'3' ,3002',3
tl .
' it'%
JOB SITE 9
.ADDRESS ��� lri iy � � Twti.�S1l�'r
APN
'76' -•2?0--(Y
OWNER
CONTRACTOR/DESIGNER/FN INFER
MMA LA wUWA,, I1:t1
SHKA.1 iOW. .
60-3] 1 Ti21,I.,0G`�' AARY.*AY-
'S1-260AV'E1dt? (12
.AQUINTA CA 92253
1k:TIgRMAL CA 928
(209:? -43.8996 C13L OV16
USE OF PERMIT :
SINGLF, 1♦AMU X D1%W_i3HC3
SAF0 • WT 134 PLAN (A"C. PERMIT. DOES ;NOT- n4CL-U]D Z BLOCK
WWALIA POOL, $PA. OR DIUVLVAY APPROACH. 2001 CODES .
CUSTOM CONSTRUCTION V23.00 OF
PORCH/PAT110 323.00 SF
OARAWCARPORT 615.00 ff
LFMWA7XD C;OW r OF OOI,VSTRUCTl;GN
CONSTRUCTION FIKE 101.0100-418.000 $1,035,00
PLAN CHKCK 101.-000-4.39-318 $$29.30
MECHANICAL HANIC AL FEF 101 r0(;0-42.1.000 $75.00
8LW,TP KCAL IME 101-000-420-000
I'jGUMBI1NO FEE 101.000.419.000 $1401011).
STRONG fMOTIOW YeE - ,PEsIU 101-000-.241-000
.GRA1)NO FRN 101.000-42.3.000 WIN ,
.i:'d i.Cmm 1tdFPe O ISN. :. $7,405.00
ART W PUBLIC P1ACE S - REZIr 270-0. 005.000
SIJB-•TOTAIL OON;'i1"RT.TG"Y 0X-AW.5 FLAN CH .CK
$4,694.93
]I,Ms pp"E-PAID Ems .
$0.00
MUTT 11 it FS D•( Y114!ow
$4,694,93
'-',
RECEIPT DATE `—'� ^' �
BY
T FI LE
INSP
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Underground Electric
Ducts
Slab GradeReturnAir
Final
Gas Piping
Steel
Gas Test
Electric Final
Combustion Air
Roof Deck
Water Piping
Exhaust Fans
O.K to Wrap
J' - j
F.A.U.
Framing
Sewer Lateral
Compressor
Insulation
d — 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
uas raping
Gas Test
Appliances `
Final
COMMENTS:
Final --
Utility Notice (Gas)
ELECTRICAL APPROVA S
TemD. Power Pole i
UIMMIWIVUllu %owR,un —
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final '7 1, Ole I
Utility Notice (Perm)
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
Enransulation
uas raping
Gas Test
Appliances `
Final
COMMENTS:
Final --
Utility Notice (Gas)
ELECTRICAL APPROVA S
TemD. Power Pole i
UIMMIWIVUllu %owR,un —
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final '7 1, Ole I
Utility Notice (Perm)