0311-076 (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
7600,14 B 0313112 t
Date 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).
O I am exempt under Section B&P.0 for this reason
Date Signature.of:Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm ander 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 offthe Labor Code, for the
performance of the work for which this permit is issued.
(N)/l 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 Sis rumn Policy No. 46-03-IB353
(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 with those provisions: 1
,Date:1'�-. c .ryApplicant ' '^�_ 'rte, A
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 fo 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 voicl1f
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 1 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/Agen�t)'� ^ti Date ` `�» ► •� "�
>: v V V — —
BUILDING PERMIT PERMIT#
DATE VALUATION 1190,951'.50 LOT TRACT 29122 �
JOB SITE
ADDRESS 132 LA.•MI Y ALL.KY
APN
7i 5 X17
OWNER
CONTRACTOR / DESIGNER / EN (NEER
(_'+ !•tME+L l3 ASI: ;
F.I RZf PACWCA DVELOPNEIrf CORP.
142017.VALLEYEILVII ^ .
S X C rfROB AV.R 5 ..205
ALRAWRA. CA 91801
R EDLANA.0 clk 92393
(909)798•36n CBL4 4911
USE OF PERMIT '
O NGLE FAMUX 1:)WFIXR10
S70,! LOT?, ?i, PLAN J& PFR2AlT DOF a NCn' 114CLUllP-iiLOCIC W.AL.L
PO04 SPR OR DRI'V s1T'WAY.OPROACH
CUSTOM CONSTRtJ.L'.'t Oil 2,271100 91r
PC p.mi1Paralo . 226.00 Sh'
0 ARAC)WA11 PORT Sia`
C00' T'' 00 C0X9X9.UCn0.PI
3 6 ID9 i„ rfT
c� � �uc�ri�a r 1171�(f 0-4le-000
PLAN CHECK FEZ ioiA000-t•:4P'-316 4792.10
,
MECHANICAL RE 101-000-421400 506100
SL.E€::2..Ri AL FU 101-000-42"00 ' $139-e3
PLt,3M811101`!3Q 101 'OffO= 19-0QS1 $ t
,
STR!C NO MOTION TtEY -RESID 101-400-211-000
ORANNO PRE 1011,000-423-000 ffi15.A0
WtZLOPEA IMPACT FFM
-'7'0MAJ C'O?a" & =70. AND PT,aW ate.-MCK
1:70
W -,R -.Mf FRES i6iiUE NOW
t'DEC01 27_"_1
+ a
CITY C <�, �� �
RECEIPT v —
DATE_
BY
DATE F )NALE,P
INS
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILg1NG APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap 4,ej-,,a
F.A.U.
Framing 6
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath d
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL PPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg: Test
Final I I
Gas Piping
PLUMBING APPROVAL,
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 /D
Appliances
Final
COMMENTS:
Final G
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)