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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 7000) of Division 3 of the.Business and
Professionals Code, andfry License is in full force and..effect.
License # I Lic. Class i`' Exp. Date
11 31. ,9 13
P
�.... �' ��-' ,,.-.rte'
Date f Signature of Contractor. �� :- �L e�
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).
() 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 maintairi 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.
( ) I have and will maintain workers' compensation insurance, as required by
Section 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 2Ef+fIMINS. CO. Policy No. 20420"WJ
(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,
I shall not employ any.person in any manner so as to become subject to the
workers' com ensation laws of California' and agree that if�l.should»become
subject to thewprkers' compensatig
^sin provisns-of'S c ion 3700 f the Labor
Code-I�Jo,�t�th comply wh thro�v�lsrons ..
Warning: Failure to secure'Workers' C..ompen'sation coverage is unlawful and
shall subject an employer to criminal -penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. ,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions:. and . restrictions set forth' on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result -of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and -State laws relating to the building
construction, and hereby autho-rrile'representatives of this City to enter upon
the above-mentioned property for Inspection purposes. ,
Signature (Owner/Agent)" Daie•
BUILDING PERMIT PERMIT# °°NTR°`"
*U16-069 3507
DATE VALUATION �l~ii.��Q..c�� LOT �t.; TRA4Jp�i$
JOB SITE„�:
-ADDRESS !)-335 ����.SER 1� i � . f� � !.
rPN
604-332.42.1
OWNER `
CONTRACTOR/DESIGNER/ENGINEER
CE;IMUe:yCR10W.;l,CON111-JU IMEES
i ils ;s . D., ��:�tx�.i:`, �i�. f��ts�
1a3� 48 �.. IV,�,"I.'R �i', �+�1..�, 4200
SAN I0XNAR.I.Mv C, 9.2408
SAN 8F RNAd,0rN0 CK 9,2408
-fit of .
(9()9y18 1 -tit w C.GRf.,?# 2120
FIEN3 P1.t'1ITN MWIL AR
USE OF PERMIT
S.lNCi,4, : RAWLY ))bV#'UING
5Sti31P.A.5,W4.(0 AVE.
TOPAZAT 3..A. QUIWA INORTE
pt AN 2n.4
9:k�+si'."t��:',�fd�'(°t�.Uf�i'it��f •, .{.,�E3a.tH1 �F
POIRCH/PA;T K) KOO '3F
(JARIWAYCA{;T(3RT 420.00 Sl~
COST OF Ir:ONS'i'.�ti3C'�`�ON
.par
�" � 87,174.40
3 YYAA,yy,Aryry1� •r ,i �L9',C��'�"I.i�9XCED
iUe.S�.t\'i.I D'EYz,>7 dit.�T81�'3�I,7fi�l '
PLANCIMCKFEM
coNS111Z:00'.{OI4 FnE 10t-t►(Dtl-41V4-ow $_W5. 50
N;47,CHANICAL: IrCT, • to i -040 -'21 -ow t33.30
isi.,Is"IC'Mlr`.,AL. FE', 3 01 �()()Q 42t3- 0 $.107.(*
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r'WTV44t14014M 101-tit1Q-414..tM 1.43.00
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FIO.NO MOTI N FEI AISS-11D . [ 0 t 41,00-241-OUO-
i.1RADWO{EI: lUI is - , Q�}� n.«Ei..l"til.
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4NMA,.�'rR.UMIRE F't,{l 0225-000-443-342 $.t93s.99
Q �D
,'.eUB-T(TM, ("CJNMC.i(MO1V ANC7 MAN C'.HEC'y►''.
$3,33454
ills Pa-mio nips
$0.00
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 7,v
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
FinalPOOLS
BLOCKWALL PP O' VALS
- SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg: Test
Final
Gas Piping
PLUMBING APP O ALS
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
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL P ROYALS
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)
COMMENTS: