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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
71 d.(88 D 10,11/19!
r;
/ate r %` 1 Signature of Contractor %,l -
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
() 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.
QOLDEN 113AGLE INS.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1 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
sub' ct to the workers' compensation provisions of Section 3700 of the Labor
de; I shall forthwith comply with those provisions. _
ate: 2r.' • 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 benefft-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
Zthe Bove -mentioned property for inspection purposes.
ignature (Owner/Agent) l / Date'-
BUILDING PERMIT PERMI J9d15_V1
0
DATE J VALUATION LOT TRACT
JOB SITE
APN
ADDRESS �ur�-3�nfD 1.fit:Qa,silt43J1E\ Il2,i+[`0.6±
6414-0191-4116
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Ct.'. ' I..TP,yf'w—)%vrt.`,commult.aiFS
CIDI M.)I yC'I:OWEL..(.,CONiMIN IU -S,
1335 80. -D- SI11HN, SIT. #200
1535 so. "i)" �iFKEET1 saT:. #2(X)
SARI 13E101A[tC )NO CA 97,408
SA:4 BERNARDINO CA. 92408
(t.;:ti9): si-(,ow CRL4 2120
USE OF PERMIT
:iINUOU' FAhiff.- D Wl:UNG
c.,
SG D - LOT -2.7.1'11 U4 2A►l - Kllki UT HOES NOT .rW LJlJ0IE 611001 WMIL
OR KIOL. '0750/4 PLAN C;t• iXX j�kll HE110C7lON V( OR MULTIPLE f`IPLE ISSUANCE
OF SAME PL,AN'li''t;F,
CR:t�CS CONSTC;IMC►FJ 1,444.00 SI
CiARt-V3 (::A"0RT 413,00 8F
lii.,STI149x1TED C)ST OF CONNT.LdCf4;:1101141
37,3721.No
PERMIT SUM MARY
Cr:?NS'I'RUC;11019 FEE 10141r1:Hi418-000 $3k•?. +�1
P1.. A 114 47M. CK T -TE I U I -WO -3139-'118 t o 2.39
1I_ $, 17.[ir4L 1-312
ab-C' RICAL FEE .101 -OW -420 -Mi
PLi NIBING F41: 101 -000 -419 -WK)
;i FRONO M0110N ,FFF - R1381'1!? 104-0(110-241-000 $8.74
GR.ArMNO IM 101.000-41"13 -0(9) 520.00
1NIZRASTRUCTUtCE FEW, -342.
d.'UP1-'1V_X_717100' AN T-) UI, AN
LESS M.F-PAJID FETS
$0,00
TOTAL PERMIT (x'EMSi 131iENOW
�2,9aHd..m
RE 1 .
DATE
BY'
DATE FINALED
INSPECTOR
II~40111ErSTILOAa I
OPERATION
DATE
11INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDWG
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
— —
Exhaust Fans
O.K. to Wrap
F.A.U. _T
Framing
Compressor _
Insulation
Vents
Fireplace P.L.
— p` — ,
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Iva
Drywall - Int. Lath
Final
Final
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
41MIAHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Cow Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final O'1- 0
Utility Notice (Perm) M. -L 1 'qq A44