9830-004 (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
101010 113119:3
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)..
( ) 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:
( ) I have and will maintain'a'cerfificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
pyrr)irmance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Son 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,, I'll,1 7;.t"iJ�y� Policy No. 045-93.010 iid'16
(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
rCode, 1 h II forthwith comply with°tpose provvi$$ions.
Date: t �1 Applicant �".;'R
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 representatives of this City to enter upon
the,(above-mentioned property for inspection purposes. j
Signature (Owner/Agent) Date 111
.f:
PERMIT# CONTROL#
�.
BUILDING PERMIT t =441
DATE�j VALUATION df 1' T AS LOT TRACT 14,95
4,9 S
-,0:4 �CJ
ADDRESS JOB SITE
�7, 3 i& �lU�t:9i
APN
76111-480-426
26
OWNER
CONTRACTOR / DESIGNER / ENGINEER
B (/ 1 ►y
i=i i..'bwl ��i tl^^ 1 'a./l�,.R Lig i. !.
/
•i itt,i�i�s 4a 11 VIA �I j fel.+
730 i'3 &T TE 31,10
79-401 F.M0.14; v�AY 111
SAN Ol}::l: 0 CA 9110 1
t,tl QUl:rd. PA CA 92253
(760Y77 1 -.1363 VBJI. 49i2
USE OF PERMIT
SM f..G 4.18, ,toLikN 3A;R, Mt-af!'.i DIX3.1 OT. 'TCL UD -4 j CCR WALL
,i&11VUL. PLAN t:;HI_'`.4.:K FE KUAf4'I. D 1117 75%)AYR YR Alil1: s'11'.LE WS' t.IANC
SOF 8Ah1, LANl ,rYt v,,
i
CUIT'O&LCvA.1^iT16U(Zrf011q 11f 3F.
Pokc-l-06+a'i 10 323.00 S
UAR,A,QFXA10'U1i f 600AX) Sp
1vMi ("14�i�;� @.3' � ��,�f
250, 795.20
/;OW"'Rt14:rf43AfFEE l.Gtl,(}C1Q-�€1�-fiiHi ` $i,3,4*t3.F1U
Pt,AFd (1Rr•.r KFE
MECHANICAL Vr-.C, 101-000-421-000 S1�.bt3
FltCTL 10CAL FM 10141}4 420-000 S174.96
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tr;RAD Nr3 F'!?L" S,20.D�
M -F kSTRUC't'URE F01 225-4100-443-3, 42 $5.545,64
AIt.1' 1N PO...TrIJC PLACE'S • RES. C 701-040-155-000 5376,99
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$7,81,6,67
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RECEIPT . ,'DATE
BY '
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
�Z l� — ��
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
_
/
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing �7d �.s,r�
Insulation
_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3 2
Drywall - Int. Lath
Final
Final ,
BLOCKWALL APPROV LS
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
Waste Lines/�
Water Piping l�/
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection�7/j j /� y r�
Pool Cover
Encapsulation
Gas Piping
l
Gas Test
S 7�9Gf
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)/%�