9905-025 (SFD)N
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License# Lic. Class Exp. Date
to i! - ' Signature of Contractor10
_
i.
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).
()
Lam 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;forwhich this permit is issued.
(- ) I have and will maintain workers' compensation insurance, as required by
Se61on 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:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that. in the performance of the work for which this permit is issued,
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] dto the workers' compensation provisions of Section 3700 of the Labor
C e, I'shall forthwith comply with those provisions.
ate: Applicant r
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, 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 1.80 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.
gnature (Owner/Agent) f Date !
PERMIT*
BUILDING PERMIT
WAis-022
DATE VALUATION $116.75309 LOT is TRACT 7399S-6
JOB SIVE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER /ENGINEER
C F,%rf � "�I Cf'..)�7 t'a..� (;(??;iC�9U*1:'l;f'sS
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E+.A.N BERNARLANO LA SY 408
8-t1N E3ERNMV)INc) CA 92408
(901)38 1 -6007 (11f,"i 2170
USE OF PERMIT
SENOR FA1v!1LV UW't;:I.i..IN-6
Sl:'.i;) - [..0 1' 15 PIAIN :iiYAR - r'fif NUT DOES N4YU lAfCl.f T0E BLOCK 6'1°M,L
OR JKKA.. "75% PLAN (141-(.:lt FM KEDLI(7fK N.FOR. MULTIPLE .E`IPLE INSUANK;'Ai
Oi, 3AIM PLAN T1`P&
7ldiii .p i iatJa7 Ki1C`PfGN 21000,M) 3F
4 16.00 3F
ti wr
t�EST P- -1 i
OF CON -- �
t 441 ted
I'MRAUT FEE' SO INIJ
COAf,`3TA.CIC'Cir..tNFL?E ltl'l-Ut!ti-�a.l'{-()tai) u6ri�Ji.Iil
P1.:aNFF4 if) I-filkl..t#q-.118
NU �"H NICAL 1 -,*`F 1 i)1-000-12.1-000 ;1.,itip
OXEC PUC AL FEN!, 101-0ttfl.14204") 9126.8
VLf,Tt41l331NG 1?EE lot -000-419-000 1-4. `7
nTIRONOMCti'ic'►t+11 t{? f23;1AT). !W-0.)-2,11400) $1!.£.R
fJiir>,Ci.f 0.1 -MM 101 -(M -123 -'.PIES) 620.00
i
041-4t.A.S!`RIXTURE F i 6 22-5-00-443-342 S2.6,F(; %
AN'F 1N PUBLIC. PLACES = RESrr"?01-I11)1)-255•• 10 $41.X11
S1J.f'{'(��!1i•C`CiN4'{kt.;�'TiON1+NDPI,ANCHECK
9,8573?
LESS i'RE-11.!111) FEES
°;0.W
'T(YI'Al, PI•:RMIT'@+I>;.FS.0tTE NOW
$3,8.52,32
/1
RECEI
DATE
BY/
DATE FINALED
INSPECTOR
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
-Framing
24 ;_/ _ 6'
Compressor
Insulation
p -zT.. 8�.2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
—717 6"
Drywall - Int. Lath
—/Z- `i 6' ,6L
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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 &10
Encapsulafion
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice: (Gas)
ELECTRICAL- APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final — 1 K
Utility Notice (Perm)
COMMENTS:
-