9810-133 (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
a's�1t'+c3 13 /3i1S�
/ate iO b Signature of Contractor (3y
t
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).
( ) 1, 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.9f 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 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:
Cartier Policy No.
STAXE FU
(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
de, I shall forthwith comply with tVose provisions.
Date: Applicant—
Warning:
pplicant 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. "
✓/Signature (Owner/Agent) t. } r ya y Date' C Z 1
l T
BUILDING PERMIT PERMIT{ 14111x(, +�Y� CONTROL#
7�f RE/K�! ar
DATE VALUATION ,4250-71i-20 LOT 7 TRACT 1,$4,94: 9 4:
:r T
J B SITE r��3� Tt��1:1�!e��aE�IO MEN
APN 'lU�-480-026
ADDRESS �a--:
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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y '
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F F�eiaMVtlY i i
SAN DIEGO C.A. 92101
LA. C?LnNTA CA 922.53
('7Fif?;t771 �;}3tj C Fli X •1972
USE OF PERMIT
SINGLE PAjdiTlN D°VE .,LTNt
SFQ, LOT # 37, PLAN 3C. PIM -MIT DOES NOTtNC U F- LOCK 'WALL
OR PCKX. PLAN CHECK f --F kR)U(;CD RY 7,-d .1;f)13 m.ui E'C.P1.11 f.SSUAN('�
OP' ,SAT's PLAN T1`t?E.
CUSTOM, CONSTW-"I 1v 3_.013, f 0 Vii'
PORCPPA A'1IO 325,00 9F
C3�h1ZAUf/C"•1�1�1�cJ.i 't' W- 0.08 .vi'
LSlla.►"111) COSIT Off CV..tNS t9.'E.7CMON
250,795,21)
CIOIN:3TRUC110N.'i EFL 1,01,000413 -OW
P11 AN Cf MIt:K E-13 lt)l -4399118 12,19.,"
N 1`MAN1CA1. T iii:, 10,11-000421 -000 w124,0Q
id's 10140-:€20-W $174.96
P1.ilE1�l1#tMC7.Mk 101 -MO -419-;000 "ni9i',SG
:1'1'R<ygr,; m, . oro-, t F.tm, wri ?:m .w t -.}f !?-�241-Mro $vuiA
03RA01,N0 :L'IRE 10. -000-423f10U 4t1.Ot1
aAf RA1Wri UJcTF'JAE 1 W 225-000.143.342 �e 545.64
ART N PUBLIC PLA.C68 - RE:siD 701-000-255-000 $3'76.99
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RECEIPT
x�/”
D'A`CE
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
Forms & Footings
Slab Grade
APPROVALS
_/
L l—� 7
(2 - IiY
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap ZZ
_
_
M/Amp—
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
Z
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
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%
Water Piping
s ��/ QY _�
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral_
Pool Cover
Sewer Connection
2 '/j -
Encapsulation
Gas Piping
Gas Test
/
Appliances
Final
COMMENTS:
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
c
Final
Utility Notice (Perm) 99