9905-036 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Divisign 3 of the Business and
(V co Professionals Code, and my License is in full force and effect.
O License # Lic. Class Exp. Date
LLJ
c Z ti /ate. -l Signature of Contractor
0.rr
J V 0 OWNER -BUILDER DECLARATION
Ulla I hereby affirm under penalty of perjury that I am exempt from the Contractor's
fn 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).
I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O�
U"Q WORKER'S COMPENSATION DECLARATION
a -
O Q I hereby. affirm 'under penalty of perjury one of the following declarations:
Fz p () 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
CO" J Q performance of the work for which this permit is issued.
Q' U (• ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of`the work for which this
4; �'I— permit is issued. My workers' compensation insurance carrier & policy no. are:
et'• Z Carrier Policy No.
• .. � Q _ [i0LLt.17l+1 EAZrI.L• 84i1
(This, section need not be completed if the permit valuation is for $100.00 or less).
O 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
subj to the workers' compensation provisions of Section 3700 of the Labor
3 C ' e; I shall forthwith comply'with those provisions.
ate: - _ `/ 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
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 Ouinta, 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.
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.
ignature (Owner/Agent) �- �' Date
PERMIT #
BUILDING PERMIT
LOT TRACT
DATE/ VALUATION 387, 372.240
ADDRESS ;8 -8�.r' )��,�1,di4iK(Li1%, CiHica,L', JOB SItd
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r -•u ��+r Iry v r�•ryr.��rr:l 1 r�.+n,rn,..r cnlrrvrrr
r •t,:•�; r-1 new r•arnirrrr I f•rs.i� fl r�n�r� �r
1535 St). "'l)" t;z r, tWF- #206
1335 So. 7+U" STREi:T, 9M W-200
SAW BERNAttC, INO CA 92408
SAN W.,,R?vAlZf)LN0 CA 9240
USE OF PERMIT
SINGLE _I 1A r ILti
SFID -10r d.3'PiXiN 22P- - s'kRIViV E<63 tai MJ,
OR, POCiL. 475r?,o P1,AN CHECK 14r, 111,)lIC"1 l0N FOR. Adi.11 1711 -fi, 1830AhG`£i
OF SAME PLAN TYK,
TR AC rC'014Jii ITCTITON, f,4G0.+?U 31-
{I%�IZ1\uFJt:l�i2!'r.jt{"i 413.00 SI'
9r3I AI A IT CO3 Of C: U'!' 1 S D. Y:i1.{C•!] ION
1.7,37!x-0 it
t:+3�19'I'ftlfC'ITc�+iv 1- 10k*0-418-WQ $ti85.50
PI, AN ('K'('K FEF, tf)i.�f1f} 1t�-31R qt?,,7,,19
irk S 1;At 1K'f t, l'1;7W t01 -000 -421 -WO 1�1 .lirl
FrLUryii3iNO PI -X 10.1 $1275
STtZ(`IN,0 NtOT1,014 FIT - ItF.SiD 101-004-241-000 $3.74
rX'ZADfN0 VFX, 11.) i X000 -423V)0
fN1'RAS'C1•tVC'PUE2f:, Fkl? 212:5-M-443-34.2 $1.965.89
ri 717."IY71".a.L rr lNS7R.11.IC"f'1()N AN O4►(.AIVt?�Fr'7 Hf,Y`.ti;
ti'► rrR{i I i
T(Ir rAli, >4'd't RNIf'1' ii'FEN DUE. NOW
S2'"' 6.113
,I+
RECEIP`[' .
DATE
BY r
DATE FINALED
INSPECTOR
OPERATION_
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/
Return Air
Steel
7
Combustion Air
Roof Deck
/,;�
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
— g,i
Compressor
Insulation
p —z ._
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D
Drywall - Int. Lath
Final
Final
7,—l0—
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater 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 6%4=
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
Utility Notice (Perm)