0307-102 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
r- Q U.) 640934 I3
1\• S 3
Z r- .Date I (P Signature of Contractor
(DO�f t,
J U C) OWNER -BUILDER DECLARATION
W W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ dCn License Law for the following reason:
Z ( ) 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).
M () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
� *V!
d Q WORKER'S COMPENSATION DECLARATION
p cr I hereby affirm under pe alty of perjury one of the following declarations:
Lo FFZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
f O � Q performance of the work for which this permit is issued.
M Q U (f) I have and will maintain workers' compensation insurance, as required by
d ()Q S` ction 3700 of the Labor Code, for the performance of the work for which this
tl 0)H permit is issued. My workers' ompensation insurance carrier & "policy no. are:
It Z Carrier XJ1,1-10NA319 U.-1 sU Policy No. 1pl�
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Q (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 Cal ifornia,land agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code,"Yfiall;fdrthwith comply{, ith tkode pioujsioPsy_
Date: 1 '1 N `E' 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
tt 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..
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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 i
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 informationis
' correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby. authorize i' presentatives of this City to enter upon ,
the above-mentioned property for inspection purposes.
Signature (Owne eAgenf) 1` t .t��a.`^i' Date
BUILDING PERMIT PERM' 0307 1
DATE VALUATION �tx7yu{ LOT TRACT
JOBSITE ��-�68D�i D�E`)
APN
05 •,2 744411
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
iyl1j. SWIM M
X -MA 1-K- 1Jli S
81.260AWIME 62
81.260 AST:te UE 62
(909)833.85496
n . • .'r m ria .maw n•
+CIATA fd#'i6
USE OF PERMIT
MOLE E 111 Aim ly M,MLINO
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3` a. o.w.yw.4O., tvt,IA1✓!�ry rrOn/y JNiOriRtgEP63Yr,airr ..w. .. .«....s....
�:UBT'Oy+ CO?ISTRUCTION ).,r`/+711DO SF
x?013u1 ?:1.d1i"1f? 321.00 4F
0ARMOCARPORT S3.0.00 VW
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,7.T:l4.f :.1'i'll'..h ,i)o WkS'.�. it `.Ff.�.7.17PJ.3.Rb'>•�
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WSiS'I'TdUCTION ' PI 301-000-418-00,101 U14Mj)
MAN C11 EC.ic, FTs: 01 V*AV_3 8 1�eti . 71
1�itrll�.164fuAt, T± a t11 n0/�0-�2 a �rrlfT $f�{€t
F;fl.£:t:'i'I<ar:Al Y f _000_42t)400
PT.i1MBP,1,0F R F; S114,(sA
S'eHDN(tFri4. Y'0. Yr FEE a RZJ JD ttJ2-000-241-'iT O $15.1.)1
01f#.AD190 FEE a 01 r000'.422.000 $ I SIG. )
MV Y-1 f 1141A IMPACT.1790. 0)
SM_,_1.,r0 AT1(y0M11 fR(JCTf01T : 3d3}, T 4 4>f"k':
S4,217.21
109 PAID I W
$040
2 U3
RECEIPT:,_ -
DATE {
BY
��prTE FI ED
I
CTOR
J..
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fomes & Footings
ucts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
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
Drywall - Int. Lath 111 12tv
-4
Final
Final
BLOCKWALL APPROVA S
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
Heater Final
Water Piping
Plumbing Final'
Plumbing Top Out
'Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral Ile
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test —
Appliances
Final
Final
Utility Notice (Gas)
ELECTRI AL APPROVALS,'.
Temp. Power Pole
Underground Conduit
Rough Wiring
Lahr Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power —�
Final
Utility Notice (Perm)
COMMENTS: