9905-027 (SFD)CO)
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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 7060) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
ZteSignature 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).
O 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.
1 have and will maintain workers' compensation insurance, as required by
on'.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:
Gamer Policy No.
(This section need not be completed the permit valuation fis 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 California, and agree that if I should become
subject -'to the workers' compensation provisions of Section 3700 of the or
shall forthwith; comply with those provisions.
te: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of Compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building -and Safety
'for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request:and for whose benefit work is performed under or pursuant -to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes nulland void if
work is not commenced within 180 days from date of issuance ofsuch
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives 'of this City, to enter upon
the above-mentioned property for inspection purposes.
Vilgnature (Owner/Agent) �` Date
t.
BUILDING PERMIT PERMIT#
9D!)4P;5.U0
DATE VALUATION Ii9913142.90 LOT 17 TRACT ?1995
` it
APN
ADDRES 43,43Ja)1,-, 715)R00KC1l[lCjel=.
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
i.9.. c, o Ni t% i L o, �! r, r !I"sfiCom;?!
U,1% X f_ RIOWE" t. C'OMMI Ni.TIES
1333 SO. I'D" SMEET, :SIT. ii AGO
1:533 SU. I, Do :1:`i'LI r p, sn. Inflo
SAKI bl",XNAROIANO "A 0740H
SAN 1:3CRNrtK01140 CA. 92,108
�)w) ks1-.t5(i 7 CB1,# 7120
USE OF PERMIT
tiil'tiil. LE' t AUv]I.LY L'1iMEt,f:rING
SFJ) -1,013) PLAIN JAR - KtTMIT DOES W)T itvCLUDE BLOCk WtW.
Olt Kt(.)I... ' 75%6111< N 0LECK 1;P1 KFDU(3'10N FoR t4ll1i. 1PLE: ISSLIiV-4C
OF SAME PLAN •rtpr_i.
TRACT CON.IT M CTlci.N i,<;'; F,fiO `•ai'
Ci�V,t:lCirYC't�It:Eri?R'I' 4 l i%.1}t� :3};
a?, i aA4ar�TED Cry lr O C'f.'ii�!.'�'1'eLE'�`$'9C.'1��'
'1�,:�;'.`1:D
C" >N':311RU "TrON FEE 1014 i) 411.8,,4.4) shl.,3 .50
Of AN tSFI-flllt"39-3 lli 'NO j2.90
111S'31Ir1�Sti"�uT.s..�x: If).i 40 1'�-OC)D :u •'.0{1
11--l'E1r` RICA , r;1, l9i-GGCi �12C?- C10 si i.`i.bi
IyLF.!AU$173i1 F7iE $134.^3
kl; . fo 1011_(M74140) 19 Rz
ORIVIli dt_i vV111 1G200)
I)uFRA.31'32t1t`'I`Ul isr pi's 27���ii,d
$011 -1 MA 4, C'O1vS'i'1t1rJt:"I10N AN1)11:ANC:1-1r,_4r
GESS; PRE -1 AJD FEES
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RECEIPT
DATE
By
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
Combustion Air
Roof Deck
- Z o- 6"a-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
. O -Z S - ^ i 6 ZZ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Patty Wall Firewall
Exterior Lath
l a -
Drywall - Int. Lath
Z-
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
Gas Piping'
PLUMBING APPROVALS
17
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
7z—l3—
Appliances
'Final
COMMENTS:
"
Final - bo `f
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
Ublity Notice (Perm)