0101-042 (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 _ lEzp. Date i
Date Signature of Contractor
OWNER -BU
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',ror 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 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:
Carrier Policy No.
(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 2nd agree thaf/I sh'outd become
subject to the workers' compensation pr viisions of $e" id 3 .00 of the Labor
Code, I shall forthwith comply with thos p vlsiops ,•�
Date: Applicant-• ""`-�
Warning: Failure to secure ofkers' Compensation coverage is unlawful and
shall subject an employe
�t6ciminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. t
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of •La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of,:th)l-City to enter upon
the above-mentioned property for inspe tion•purposQ�•'°
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DR � VALUATION LOT 0'10.1 W2 TRACT
JOB SITE
APN
ADDRESS
°79-0-75 LAIDE i,a1
OWNER
CONTRACTOR/DESIGNER/EN (NEER
74.3 33 HIGHW; X 111, a31UE 10;3
74.333 :ts'3`sVY 111 OKI 103
PALM DI��:wJ. CA 1126x1
P1AU�(1[. 1r1(1^,'�1((�RT .CA
T2260
�9
i U�IJ� iJ��Y S•i f4.�.i�'4IJ 5(YZ / u Q
USE OF PERMIT
'W
-VI IZ i'.f'MIL2 D'4J4MLING
SFF.k•l.,[ t Hi P),AJ4 4A,,, P@.RI4QIT DONS NW xi+il",k,i 0F_ B:ieCCK WAL14,,;
P007, 0n DRN MA'`t' APPROAC, . 9 L, 1 F!`G' is h.L+'•Oi)'CTION FOR
lb`I'ESVf'iP). Z ISSUANCE OF ICAME P$ -AW 'f'YPM
h
TRACT CONSM10(11TION I ',,VI 0.00 IV
'iZ00 S?
�POg?�i�6,:(:��/?JgA���R"R�£¢i��7'� yin( (y y� (
fa. �.l7'!d'ii.YA47lri1��'0..R.T"OR (0) J.,465,60
C01 7MILI ' T ION ME 101.000.418-000 $814,50
PI.A:t4 CRIEC,K WE 101-000-43941.8 $1?1.(M
ME"UatC.fE19 .101-000-421-000 39330
F-FCTRIC L FL?E 101-000-420-00/$.W.v
PLIMPINO11F{%'. 101-000-419-0019 SY74,50
S' 'F`0110 MOT1014 t % • � LS`9�9 %07.6}0 7, 1-tTOi� $I4 �'i
Cii~ADINO PC, it, 101.000.423-000 ROM
IpE!"IuF"P`R IMPACT ME $1( Wa, o
j
SU'F>�•'�'S�aF �:1.1A4: "1GaUG'°11CJ1�i l�1 :��:(i
V4,:3e24.1t'8
�q��rrulcc�� ry5�3Par~tyE
RECEIPT
DATE /j )f !
I I 4. 1 l.' !
BAY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &Footings
Slab GradeReturn
Steel
Roof Deck
I 2q
%
RA
r^� _
CC
Underground Ducts
Ducts
Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
O.K. to Wrap
Framing �Lp CaFgsc,
Insulation
��2�
��
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�rgc.JLW 2'
cp
Final
BLOCKWALL APPROVALS
Final
POOLS • SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
`
Underground Pibg. Test
.Final
Gas Piping
I PLUMBING APPROVALS '
f
Waste Lines �_ts�Y p �L
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
_I
�'�
O.K. for Finish Plaster
Pool Cover
Encapsulation
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. l �/
Smoke Detectors / /—•
Temp. Use of Power
Final
Utility Notice (Perm)