9909-078 (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 buSlneSs and
Professionals Code, and my License is in full force and effect.
License Lic. Class - Exp. Da e
��J311.i�.' .
14
/te�r1 Signature of Contractor,/7)`'�f-�����
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).
O 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:.
O 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.. .
IIhave 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.
001,1MN EAGLE INS, i.�fWC .�t4068-Q1
(This section need 'not be completed if the permit valuation is for $100.6d'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
worke��ompensation laws of California, and.agree that if I should become
subct'lo the workers' compensation provisions of Section 3700 of the Labor
C9de, I shall.forthwith comply with those provlslonV ! '
F,Date:4t Applicant
Warning: Failure o 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 'hiss
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 upor
the
above-mentioned property for inspection purposes. f'
Si nature (Owner/A'ent) e 1.6^' � LC 1! Date �`� / � ✓ 'it=
BUILDING PER!JIT PERM
DATE VALUATION $99'1 LOT 29 TRACT 21399_5 7
JOB SIE-a� �1T,Ft��,%
Fe1D4 �SPJ��O�
7APN
ADDRESS
OWNER
CONTRACTOR/ DESIGNER / ENGINEER
CEhI'tMJWY C;..37.C11E.(,,,1, CO?MiN:i' ES
CEN'1`LF1iY C.'RO-%-- L71, , COMNI.UNITIfsS
•
1535 SO" -D" �"�R13 , SIP 92.00
SAN l�FRigAl,:�1K0' CA. • 924014.
SAN' BERNARD INO CA. 92408
l ?u;�i?i l ^eai�fl l 001,9- 2120
USE OF PERMIT
SM11J,, FAMILY CIVir'iE?7,l,.teNG
ak' t- UYI` , k0Lit-V 31114 - PL','aiNIV Yj.t .3iv;) v. V4. V L, ULkX& WI -ILL,
OR POOL 75P,,S.RF1D11C ION i?NPLAN CHECK FEE. (')1( )Vf(X'T MLR
ISSURANCE OF SAIVM PL" TYPE.
TRAC t' CONST RUC" - ION 1,679.C'A tit=
0AIRA.t►t7!'CAiPORTl 1'7.011 S1+
t S11'IY A1:19 DC�99�'.�GFIMINS"d'➢��1'�".f` ON
9�,3��2.°819
0ONJ'1'Rtit^'TION FEY, 101-000-43."00
PLAN C HIEC K FIX 101-000-439415 11,132,96
NWCHANICAL FU 1010101.000 &47.410
f;:ll, K.:TRT(7AL FEE IC1I' 4NJf?F��tY-fK10 �f.tg:St
1Pi�i1RHRtl'C.FL`)x 3'si1-Dtid)"91�-Ot)l} 1134,75
TfPC)NO MMION FU - RE'SID 101-M- Z141 -;W0 19.93.
GRAVING FEY, . W1-000-423-llW $20M
13&•VVIO:t'1E iMPA(7f-1F 8T,
3' • _
SERB-'RYFA1.+ C O1`'S'TRUCt"1CIN AND PI U4 HECK.
Lwb ,' t-1��1iD ; 9i.G
fl.g3tD
TOTAL PERMIT FF,
RECEIPTDATE
�;.
'
sBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
/ _ _
�l�
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air i
Roof Deck
►" L
Exhaust Fans
O.K to Wrap
L '39 _00. 1Aof
F.A.U.
Framing
/ ��®
Compressor
Insulation
�, - 2 S' _a7 ®
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines'
Party Wall Firewall
Exterior Lath
j, — t _ 00 l
Drywall - Int. Lath
'3- g _ (go
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�L
Sewer Connection
r�C�
C
Pool Cover
Encapsulation
Gas Piping
Gas Test
.L
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) 'S • c °I _ p�
COMMENTS: