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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
714188 B 10131ii9'.
,Plate- 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
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
S;Xon 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:
CarrierPolicy No.
Gr►L;;.�;7d 1{,�C•L1 1 L
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) l: 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
C9de, I shall forthwith comply with those provisions.
pate: Applicant a r'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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.
gnature (Owner/Agent) ' > ! Date r�
I
BUILDING PERMIT PERMIT#
'3iDfD4 d1.+)
DATE ' VALUATION LOT TRACT
/ $99.342.90 to
'
APN
ADDRESS :► �:� T aDB. � )11i�O��A 1r��ti'�.�:
"4-040-016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C.'1,ITIT i11.Y C IIIIIO �rf�fIL C10" 111�1.It'11i'11 u
C P T1,11ty, ICK( .11 IA. COMANILIVIM[ 1 I.E?.Ci
1535 5th. "D" ,S'['IxEE T4 STE. 1,12100
1535 so. "DW SI'tLECA l , S.I`E. 'u200
SAW}:tlrld;:vll.iLC INO c;A. 92408
:SAN BFkNAitC►INO CA 42=1011
0XIM191-6007 C1111.4 211210
USE OF PERMIT
LOT M PLQ-4 304 PJ' t4fi'T DOES i.IdC1.i11�L IsL�3+ `•l: WALL
OR N(Xil- -7,V, i IJLA14 i::FIF `K f �E Idii[: UC TION 't" OR. NIULTIPLfi V'-SIJ#V4CV-,
OF SAA1V PLAN TYPI -
TRA(- ' (XrNTrRU1C'1-10N 1,41119.00 ,>r
Gil RA.Gt C:'Alif -.3l;Uf 417-00 5F
3
143TINIATL1)4. OST OF C0N yJ eUCA`10,N
PIERAUT ftX SUM MAR
C: NS`t1¢ QCfK)N VEP 1.014)00-4111»0(1(E r;15�.ir3
PIAN 01,"X 17PE' 10.1. -(N)0 -r)39 -1J H $131911)
INMO LIWOCAL R'4 1(11-0(10-d"i 1}1)Q 1477x)
1-1ECTRICAL FM t1.,:;.61
PLtltW1BIN'kJ FEE S134,'1.*
S'Mr''W" MoTfON FFI.. • R ?S11) 1001.dx�ty(�1-141-IM�Jf()1 10 93
ORi}!.►1i'Ts,L ')3i [VI`WJV'tt �'[ll/�l Vri.tir)
INFRA" PROC;'1"i:'ri:<f FEE 22-5-00-W-1441 5;2.W35.�2
S1a13-T(YI',A1-CONSTR 1(Mt. N AM) p1<AN C'1)I:CK.
$3,:'1344
L)3SS PRE-7PAID FEES
S0.0n
'6'WI!'Adl PY+;DtAQFf MEN DUE NIM,
$3,314.93
RECEIPT:
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
-7 —r'- 19 9/
F.A.U.
Framing
—
Compressor
Insulation
1.
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
v
Drywall - Int. Lath
Final
Final
14 4—y I 6'
POOLS - SPAS
BLOCKWALL
APPROVALS
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 APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbin ,Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
/— Z7Z7a d -
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
Final 1-
Utility Notice (Perm)