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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, and my License is in full force and effect. •
License# Lic. Class eExp. Datg
Date Signature of Contractor
OWNER -BUILDER DECLAR.4TION1
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). s
() I am exempt under Section , B&P.C. for'this reason .
Date Signature of Owner
� y.
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. f
( ) 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 2E:N:111-t I1v r: t;U Policy -No. .2(1ii"em)1
(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' co//Apensation laws of Californiaj-and agree that if Ids ould-becolnTe
subject to he orkers' compensation,provisionsS61_ io�3700.of-the L-aber
Code�j aworth ith comply with those provisiohs.
Da e- 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 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/ene.,6pon
the above-mentioned property for inspectio*n,purposess.Signature (Owner/Agent-)"-- =' Dater
PERMIT # CONTROL #
BUILDING PERMIT
�.
9606-07 1 3 509
DATE VALUATION i,t-ta LOT TRACT rj_ jlfl{�
- -
OB SITE
ADDRESS70-3 555 0U.St�IM11 C:ttRS1 �3dU'Vi+,
•OWNER
CONTRACTOR /DESIGNER ENGINEER
I'LL .iuYNAANiiIi F
WN"11JR ♦CC',_,V 1.,LL CNIMLTMI'111-' ',
1535 So. 111t" >"i'}a.E.r.1, si'fa. #2()o
i.535 SCS, "17 4STUE,7r, 8713. ff200
tiAN AF-XNA#t IN, CA i�24 8
SAN .0 ERNA,li1)INQ CA 92408
i!u4)ca)3f�f-Cf3(;'1
(<t�►};�gf-6flt`t? f:�ll.fd x7iQ
USE OF PERMITiffJ'll��(j�
IitiVii1.f.ING
M391wSsaw 11 AVU1.
1.. v.'Noti:1r, C! w's'.. s
Tr.;1 A7 XT x A e►UHOMKUMT, '
PIAN Z'A E►t
`i'l+t�:v!'L.:C)N.°�"('iif.11�."!'FC3?�r '� f.4�:3.1tE► �i!':
1"t) iC01PA.T1.Ca �`� 85.00 8
GARRA0l�.JJCARK).RX Sly
FS'i'IMATED COS'e OF CQNS.TRU l ONO
87,174.40
1'1x3 MII 9VlliV;lWARY ,
vr_.1l�ctlte�1�1�;tt� 1At•-�4a�-�i�t �f�s�,�y
CONSTitttiw"1ION114M 103-000-418-000 ��?� . t►
W(If ANT -CAL i lffi 101.000421-000
'r121C".AL FEE, '101-000-420-000.s 107.06
X11> s) G 1r1 f • IC1 i iif}"4l > (i $148,00
�
S���[['��tiINGy,IMC7TfION 1IM- .RES1.1) ' '10011-O#W2411,00�0
i
.$8..12
tiJh.RiLJL1�iC:Y f.IX-1 10t-000-421000
'1N'F1t. Cr1IRLIC`"i'tll2k.F"f;'a'"s 225-000.443--342
SIX -TOTAL CONSMUC71ION AND PLAN CIMECK
R S.3.,3504.
LESS.ME-PAID1:EES
, $0.00
TOTAL PE-RAUTUMES DUE NOW
$3�35 4. �4
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL P ROVALS
I Bond Beam
OPERATION DATE INSPECTOR
!MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
Steel I
Electric Bond
Main Drain
Approval to Cover
Final
Gas Piping
PLUMBING APP OVALS
Gas Test
Electric Final ;
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out VEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
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
Utility Notice (Perm)