0305-246 (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
Dated :'.) '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).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaltyof perjury one of the following declarations:
O I have and will maintain a cerUflcate 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
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 NATIO", UN302+I 1r Policy No. '703530.0
(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 shall forthwith comply witlrthose 6visio,ns
Date: Applicant -
Warning:
J • �(.��� 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 this ,
application.
1. Each person upon whose behalf this application is made & each persomat
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 ri
& 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.' L
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 authorise representatives of this..City to enter upon
the above mentioned property forlinspectionip'urposes.
Signature 10.wner11 "1111Date
BUILDING PERMIT PERM T#
''
DATE VALUATION LOT!.tJ! TRACT
• 4 .--- —
rfis 3,0023
� . �, ,..�.
JOB SITE
ADDRESS • ,
APN
764.270.017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
i. H011,M43FOR AMVE ADMIS .
URMHMM.
-"60-,411 TRLp.X)GY PA?MW AY
LA QUINTA CA 92253
T1VW.&NT. CA 92883
(909)833.8996 CBL# 6$76
USE OF PERMIT
9MY E FAM, 7J ?�J�[r1C4
FK1- LOT78 PL. W4 5515A. PEAM1T T)O&S. NOT TNCL:rUDE Fi..00K i
WALL% P004 SPA OR AWEWAYAPRROACH
CUSTOM C014STRIICTION 7,45COD SF
PORC''11MATIO 179.00 SF
QARAWCARPORT 00 ,'"stt
E�s°� AT.11) C-01A7C OF CONIV1RUCUM
QT��O #3.dsCi
-
CONSTRUCTION FEE 101.000.418,000 SL903,50
PLKN CHECK M1, 01-000-439418 $917-76
MC1LR`NICALfEF,t 101.0004,21.000 $96,00
ELEC:9.TRICl?: FFV, . 101-0010-420-000 $179.02 ,
PLUMBI NC3FU 101-000-419 -000 $160.00
STRONG MOTION FEB - R 310 101-000-24.1-000
GRADINO FRE 101.000.423.000 SI$,00
WrArE )PER IMPACT YKE
t�ilifi I'P1 PUBLIC PI,ACHS -RESIT 270.000-445.000 $9.:63
COMMIR SCMONi AND FLAW CH.EMG.
$4,02.24.
M-33 PRFPAWFERS
$0.00
.
RECEIPT
DATE' '�''P. ,)i
BY
T FINAL
IN TOR
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- '21 y- -.5
Ducts
Slab Grade
- Z.—
Return Air
Steel
,2
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
i-
Vents -
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPRO
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 APPR VALS
Gas Test
Electric Final
Waste Lines
D 344V
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/ 0 v
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: