9911-034 (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
Liw3, WWUWA�
Date ttt 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). r '
() 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
pe ormance 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:
Carver Policy No.
IN ', COWA OF 'T. VIDE 1.7004 1900
(This section need not be completed if the permit valuation.is for $100.0.0 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'provis'ionsoj,Secti n 3700 of the Labor
�rCode, I SAA11'fortl�Ath comply with those provisions;..
�7ev
ate: Z'' �� 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.tFie 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 plrrooses.
���. r :Date i ' lel ,
�S'ignature (Owner/Agent)
BUILDING PERMIT PERMITk
DATE�„
( % VALUATIONj��,��4 LOT TRACTJOB
SITE
ADDRESS 5��'525 V-PY1aR.rAU,W.tLL WAIVE,
OWNER
CONTRACTOR DESIGNER ENGINEER
11C
NIT "NyiESryiYy,f
P0 . 1411.
VI IVL9� R.U. 4S i
LA (lILJIN tlA '' �''. k. 92253
k'H�yt»M;1p'dix AZ W3 i.l")
USE OF PERMIT
S- M - LOT 8. PLM4 111k - PETRivii T DORS IKO;i' INCL-LIri E BLOCK WALLS
OR iF _)QL. PLAN (.'RW -!,K POW110IN OF VEX's.CLEDUCKD MUi.,"C.iC'I,:ki
t�SAif13dC;}s t'r.F SAt1ti[3 3R&:..t'�fif 'I"'Kifi•Tr .
13ARAILOCY•td{f"O..RT498.00 8!•'
PFIR IT FRE ISg3ii M&RA'
ACt:1.t'7S',FRU(rCTON f'AU 1014)(W -419 -WI) $1104100
MAN CKEC"K FEE,
MCC:II11MCt 1, F101-i;ti0-421-000
L-J.3:CTl11C.AI.PEE. .101,400-420,000
.ry�.C.f,'12bt�3Lxf�-L�ffi ., ���-cx�.��s�•OOo _ $It�l.3t�
,.
sy1tRt'1iNKi M•0'i TONT TET,: -REM— Iflia{'Kl(p414100 52I.49 '
t RAIDINC I�' , 401-000.42 ()00 s�°�. o .
[A lrE?LO1'IMLWA.CTF—FE
�fi3.R••'ii:,XT-�,
i -
LESS PRE11-NUMPEES
0. 00
TMAL PERMIT Ir+UNS DIA; NOW
• �4
r
RECEIPT
DACE;
BY rl C��
DATE INALED
INSPECT
INSPECTION RECORD
OPERATION
DATE I
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/,2 —
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
��
Exhaust Fans
O.K. to Wrap
«. - !r/
F.A.U.
Framing
ej
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—
BLOCKWALL APPROVALS
Final
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
Encapsulation
Gas Piping
Gas Test
=Z7�
Appliances
Final
COMMENTS:
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) Z. G(/