9905-010 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ci W Professionals Code, and my License is in full force and effect.
O -=) M License # F Lic. Class Exp. Date
1-Qu7
ti UJ1111$!3 R I Ol t 1.119!
�3:
Q Z iZ /ater ' - Signature of Contractor;CD
J'V (D OWNER -BUILDER DECLARATION
LL1' W I hereby affirm under'penalty of'perjury that I am exempt from the Contractor's
.d 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).
co O I am exempt under Section B&P.C. for this reason
LO
Date Signature of Owner
0 CM
a Z - WORKER'S COMPENSATION DECLARATION
0,It dr. � l hereby affirm under penalty of°perjury one of the .following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
K -LU LL compensation, as provided for by Section 3700 of the Labor Code, for the
_J Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
J U Q Section 3700 of the Labor Code, for the performance of the work for which this
L rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'Rt,: Z Carver Policy No.
[.101ILDLP4 isAGLC !'NS. 55,1
:tl�tia-4 f
g(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 whichthis 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
Code, I shall forthwith comply with those provisions.
ate:t,- esApplicant—
Warning:
r' A licant
f, _
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 3.706
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 l 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) L i . / Date r'>,
BUILDING PERMIT PERMITq
"W%410DATE
VALUATION LOT TRACT
JOB SITE'
APN
ADDRESS 45-4.80 8ECR 11 (�I(r1;�.LE
)'r�
��i•�Q�-QST �/
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C111:1^3'?.'I.Tr'.Y C1, )lh't;t:r., c:°c)ltii�lr[i art tr �;
c._Y?iV'r1.1�:Y r��c) rVEa,G co�tAbhTsrrrhs
! 535 SU. "DrkEf-."r, S.rC: #200
1533 so. Simi T, SCC'. 1;20-0
SAN BLRNr1ROrr 0 G.A. 924M
SAN 6F1'R JU?T)INt:) CA 92408
(")381-6007 CIRL4 7.120
USE OF PERMIT
SINGLE Ft AfILY DW LLING
4t) - L01' 1 11t,AN3S - i'Liti' IIT:i:K: ES 1vj i INCLUDE BLOCK WAIA. OR
TRACT CONSTRUCTION 1,6111.4.06 31F
[FrtRAs3!?Ji��ti12f'+UFL"1 41'11.00 SIS
E,S7'3hUTED C ST O11' ICONSTRUCTlON
I•„ 2,! 1
i°EA0 1 11 b4KE SiUILIMAR't'
CQN 5'1.V.tfC 1'tQN FIFE J OI AXV-418-OW 3639.50
N.1: A.)'1 i`4FrK 'F°h',r.•. W 140)-di4-31 R $531.39
NO=. HANICAI. F11, !t)1 0{t( _, ?;.:.Ur)4 &.1", t)
Urt;:1111CAL,.1 1Cii-Oi)ti-a ii-oi J S1: .61
PLUMBING FEE $136.75
STRON,tC 100TKYN FE13 - R.FgrC) !01,,000-2.41,000, $9.!6
GFtAH1tiG .NEE It.11 ••G00 -,r ;)..C()0
1NFRA:il'RUClTUR FEE 225-000'413.3.12 $. ,►5.2d
1`103 It3f7"gSt 1' rut (M?U .8�f :3333 bx�+).{n7
'S 1B_r'(' rAl, C(;►i1iSTRIJ("110N A;'19 PN.:AN (H('{.'K
1.3 711,,
1,1; Pr�:4%11) FETE.'
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"!•(]r` AI, 11111:@iMIT Flt,ES OUP, ti+0W
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R t4BT
DATE
BY'
_
DATE FINALED =
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
A
Under round Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
r
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
Compressor
Insulation
7_--Z-7-27 JE&L
vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
�$
Drywall - Int. Lath
D —
Final
Final
—
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
4V
Encapsulation
Gas Piping
Gas Test
—IT P
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit "000 -
Rough Wiring
Low Voltage Wiring 00F _C7 Lor
Fixtures '
Main,Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perris)