9705-043 (SFD)LICENSED CONTRACTOR DECLARATION
(D 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
CV W Professionals Code, and my License is in full force and effect.
p =) c7 License # Lic. Class Exp. Date
rZ i
Z LDate�" ~' S ✓ Signature of Contractor' f"
O r
U °� OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following- declarations:
Fp ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U)• 1 have and will maintain,workers' compensation insurance, as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit:is issued. My workers' compensation insurance carrier & policy no. are:
;I- Z Carrier Policy No.
0
J (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-1 should become
3 subject to the workers' compensation -prove cions of Section 3700 of the Labor
Code, I shall,forthwith comply with those pro lions.''
Date: `� '� 4 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 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 reve entatives of this City to enter upon
2above-mentioned property for inspection purposes
nature (Owner/Agent) , Date.// f
BUILDINGPERMIT PERMIT# CONTROLk
5 0 99
DATE , 1"I VALUATION
eft LOT f�3 TRACT
ADDRESS 78-7ZO 11"iACARA'�D1��U., JOB SITE
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
!' 1'f !:1l:Sl t:`!' 1'1! ; :'1 : 'Ot'" tt:"J`t=..i...`.
`�;�r1:6:::..; i.;?;w�; !'I:' J(_;'t`.iC3xJ
P.O. BOX 1716
4 IS RANCHO LA QVINTA Nt..
IA Q1.11h'i'A GA 922,53
LA. (�1.11N'3 A C.A 92253
i ylt3►77t-i!1ii CTBT t1 29196
USE OF PERMIT
t.lsitttti;�.ti, %1,A:fi t
I -PLAN C11kCK VfW_t k 011,at. E0131` ?5%3% YR XKIIJIPLE Vi AJANCE OV SAME
PLAN
d,'ti s;1'C:fy1 �'i�IV;577'�tJii f`i.e:?tii 2,'�31.tJt7 SH
1'UkC1 �YA`.�lr_► 174.00 SI~
t?r111l.i.(91:/Cr.F'lfW)KT 4K00.1;F
EST IMATED COS Of CONSTRUCTICIN'
13.5 0
iii±".RMIT FEE E SUMMa Wk*
.".15
PY,AN C'11fs"t' K FHF 101-M-439-3)8 Slit
...•�
CC?NM'RWI CIIN 1"RI 1,01-000-415-000 5+�
x�iWI1AINUCALVAl'2 lot -000-4111-000
fiLHC RIC'ALIU i _.101-0()0-420-000
101-0(.10-d19-tiQO $:142.00 �,13TQNO
*ft_•°
M(yrf0-_wiai f -1i1 >O 1+.31-0n0-24(-4141() 5119,54
(MADIiiG F'E8 101-0004D•U00
C
(NFRA`.iTRUCIrU%'i.', FEE 225-000443-342 $4.124.11
� (1
Ak'T 1N PUB1,1t`PLACf1S-RG:3tr, 701-000-2554)0 $233,95
J
ESQ
0
w
S rB-TOTAI, CONSTT'1tt.TCT ON AND MAN 0-MC.K
$5,919 67
LESS
TOTAL Piltil"1ff T'k;ES OVE t OW
V5,419.67
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
4+
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
g'7
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
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
2-2 —
G
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 PI . Test
Final
I I
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
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:
'