9905-042 (SFD)LICENSED CONTRACTOR DECLARATION
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
N W Professionals Code, and my License. is in full force and effect.
p :5 i,) License # Lic. Class Exp. Date
In
W 7idlf�fi 1 iUi3i.ilnt
oZ ti Vdate ' Signature of Contractor
tooti
J U CD OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty, of perjury that I am exempt from the Contractors
~ C- 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
U O I. am exempt under Section B&P.C. for.this reason
N Date Signature of Owner
0,
d Q WORKER'S COMPENSATION DECLARATION
oI hereby affirm under penalty. of perjury one of the following declarations:
H p (•) 1 have and will maintain a, certificate, of consent to self -insure for workers'
X W. L� compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
QQ Q Section 3700 of the Labor Code, for the performance of the work for which this
(L 0)H permit is issued. My workers' compensation insurance carver & policy no. are:
S Z Carrier Policy No.
' O rl i_L`fiv F {:I. i t''':�.
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 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' '• to the workers' compensation provisions of Section 3700 of the Labor
3 C e, 11 shall forthwith comply with those provisions.
gate: % Applicant-
Warning:
pplicant 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
fore a permit subject to the conditions and restrictions set forth on his
Application.
1. Each persomupon 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, indemnity
& 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.
ignalure (Owner/Agent) i at (`,t, Date
PERMIT #
BUILDING PERMIT
99411S-042
DATE VALUATION $37,372.81) LOT ,Ai) TRACT
JOB SITE l /
APN
ADDRESS ,�S-420 D ''ED��iiRCPi'. K CiIRCLE.
irlii 4�S�iI gI)1/'i
OWNER
CONTRACTOR / DESIGNER /lENGINEER
pp t �y� ■ t
C�'�OW ELL lcohh'iNi 41irii 17C
1�
i 53 5 Sv. "D" S i'1_CE , &FE, h1200
j 5W SC;_ "U, , s i c, Fi', S l'i;. 4,200
SAN B RNARDINO CA g2A1 8
SAN 13F.RNARLANO CA 12409
(�tWl:it3!-b00'7 f:L'L,;`f ''120
USE OF PERMIT
St lVGLE FM11fLV DWEL1,1NG
r
5F0 � - L0T 2Y PLAN Pai !n, I)cic, ; ,14c i' IfSt i lvl"s 13C,o6: wy/ u,
Olt PD OL, "?Y,!n PLAN C,HJX,1 FEI?, R0 sttisTI N FOR MULtIPLL ISSUANCH
tt`' SANIF NI.. (xN TYPEL. .
GARAGUCAJiPOR F a 13 +r4 F
6l ':IZt-k7TS Cfle+ C't_1"\ryt`�tuc,'d:ir]
^.:�7�.In :r
11" EiY'i►+ IT 'FEE S UMM MAY
C0N ,'ZrK lC1*k0N IX1,014 JI -418 -ow $533.so
PJJ N ('14ECK IFFE7 101-{K1fd-439-3119 yf;'.', 3�)
i1 EZI1AtQC V, F? ;,E S47,00
HLI.CTRICAL FEE iGi-0Al?-d%U-iiljs) st070;
PLUNIk5l NO FEE 10 L-OWt--419-000
S CRC.> --140 N1.0110N FUE, - RIF3,11r1 101-000-241-
(iluiinNo ruc 101 0004232 -MO $Z0,00
INFWkS'i'RVC7'ORE Frr. 225-000-443-342 81,9�.S.ttS+
_J
AND KAN (.MECK
12SS PRETAID VETS
$i1.l;fl
TOTAL PERMI'l?' FUES WIF NOW
$7,986.1.3
RE PT
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
-/ -
Exhaust Fans
O.K. to Wrap
V0_X_
F.A.U.
Framing
g '
Compressor
Insulation
p -
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q —2 2 -
Drywall - Int. Lath
Final
Final
- "-60 1 r4
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
CL - 'S� /
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
107
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
p -
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) - Z (.- mCTT
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) 12.22