9905-026 (SFD)r LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F� Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
co License # Lic. Class Exp. Date
w
L
U) 41 1� 103 1 i i it
~ Z ate Signature of Contractor t
C0r-
�O _ 9
U cue OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~'a 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).
�
O I am exempt under Section , B&RC. for this reason
N Date.. Signature of Owner
rn
U Q WORKER'S COMPENSATION DECLARATION
• IZ _.
CC I hereby affirm under penalty of perjury one of the following declarations:
r H O O I have and will maintain•aCertificate of consent to self -insure for workers'
X. LL L compensation, as provided for by Section 3700 of the Labor Code;, for the
mQ performance of the work for which this permit is issued.
<C, (� O I have and will maintain workers' compensation insurance, as required by
Q V: Q Sectlon 3700 of the Labor Code, for the performance of the work for which this
d Lo-
a)F- permit is issued. My workers' compensation insurance carver & policy no. are:
14h••Z Carrier Policy No.
CSC LDIG ti E AGLAG 114S, ' ,
g(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that inthe 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
r
'ct to the workers' compensation provisions of Section 3700 of the•Labor
, I shall forthwith comply with those provisions.
. Applicant
.� t_ . ...
Warning: Failure to secure Workers' Compensation coverage is unlawful and
stiall'subjectan 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,perrnit 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 160 days will subject, permit to cancellation.
I certify thatI 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.
.Signature (Owner/Agent) I Date r f
BUILDING PERMIT PERMIT#
�,�i►;ti-bl�di
DATE VALUATION S14%,9E+tl.21f LOT ;3n TRACT .► ,-N5 o
JOB 011 E
ADDRESS b•�-+IS iJE� �ZS �kC�dD� 9➢�t 'i..I�
PN 6041-040-0.16
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P'EllN I1.Jx' Y' "F:i")W.,"i,1. ' QA''%Ef_;�1nrII:5
Ell N, s ._ . , ti (
v
N. TfiR Y CR.C,Wl''r L C 11.[°''(rrnr r r1''S
7 t.4, -IJAV t. i. ami i 1.
i X33 iX). ".E'1" *a l"K1:E"V, 9R, �, ri200
Baa SO. "L" S> i H E ETT a M, ;i200
SAN 61-AtNAKIANO CA 921108
SAN B RNAItI::il.i O C"A 92,108
i �t,1a'►3u 1-�sI10 � I,i:11:R�f 17A
USE OF PERMIT
SINk'01A, MWl,1` 1.iWl:'E LINO
Si'ia - i.OT -16 PLAN 5C - PPYONfiT I3CiUS NOT INCL UGE BJ t,"M 1b AIA. Elft
*75% (ILAN CH.[X s I EH 1dJ.)LI TI+C1N FOR ibft ILTIPLE .13,*PJ NC;F' Cal,
titlt4lf PLAM'f'YPE.
i RACT SF
QAI AU[!YCEil PQRT 698.00 SF
EST114ieaT. l:0 008- OF CONI T RUCTIONN
1 fl,6.9631 10b
C0N.',.TRUt rIUN F05 101-000.11111-01,10 St664.(0,l
PTI AN (11r -TI FFIF 10 1 • 0f )-l'0..'319 $117.71
ry ECJ-W41CAL FI%, 10.1-000-421-000 $17J)0
til kl TIUCAL F&-. 11014"420-000 S122. _S9
PLIJA4l INC Fi?E 1.0t -WO -419-000 $134.75
STRONO Ill,ujTIONWO -1?r S"m 1n1.^10-214.1-n(►n t(i.7(►
CiRAI)INC.:11 XX lot -000-42-3-000 �S�r1.QU
fNI` RA`a YR1JC" I UKf 1 FIE E 2254W-443-342 32.4l►S. N..
rIWr IN PtAgAC K,AI_J*-i' i - RESIC: 7014?(?0-255-OW $1'7.4'2
S1i.T.1-TOTALc'r.►NsTktI° ICINN ANT) E't..ANt x-;1:11 C,K
SO 195
1Al'SS NRT,-P $1D I-'I:?E'S
to.f)0
I'i` TAL PERMIT FMS DUE NOW'
53,560.95
4
REG IPT �
DATE
BY' "^
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
- Z0-
Exhaust Fans
O.K. to Wrap
In ea
F.A.U. _
Compressor -
Framing
Insulation
d - Z_ 6'
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-.Z-
Drywall - Int. Lath
Final
Final
POOLS a SPAS
ELOCKWALL
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
7
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final ., 7 5 -60OW
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring '
Fb(tures
Win Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 1 l a- 00
Utility, Notice (Perm)