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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 Exp. Date
i oil W-71
Zate-�Signature of Contract r
OW NER-BLIII_6g�R�,E_E�__ _RATION-.
I hereby affirm under penalty of p�rjury,that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, a,5 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. �044, Business & Professionals Code).'
( ) 1, 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 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.
I have and will maintain workers' compensation insurance, as required by
Settion 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.
Z041TH INIS. M
(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' compensation laws of California, and,agree that if I should become
sub' ct t the Norkers' compensation provi§ions Of Sectio_n,370'6_�f the Labor
0
f
�d: I shall !Ortpl with comply with,those provision
V ate
ate: J Applicant--'
re to secure mp
Warning: Failu WorkersgCo� —coverage is unlawful and
0,asation
shall subject an employer to crimifial-pi-enalties and civil fines up to $100,000, in
addition to the cost of comperfsla- n, 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 persowat 0
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,_arid State laws relating to the building
construction, and hereby aut,horizer,representatives of this City to enter upon
. . ' BUILDING PERMIT
DA�Epq /,1 -7 /,-
VALUATION $106,07.111)1) LOT
JOB SITE 4-5,"4)
ADDRESS
OWNER
C 11h
IMIRY x C
SAAN 8FRUARTANO CA. 92408
PERMIT# CONTROL#
r.44
IT TRACT 2
APN
CONTRACTOR / DESIGNER / ENGINEER
.1515 so. #2W
SANUMVIDING) CA 924W
COLO, 2120
USE OF PERMIT -, N)AWN AGWILAR &SS00-ME-S
AVEL
PLAN' 613
PLAN CIJF�C-K 1,41,FS I(EA-11ICT-Wo WISE 0F -SAN%.'?LAN
IfIZACT CONSIMUCTION V
tiONTMIX03) CUSTOF CONSTRUC1,101*4
Pi?,RM1T.FF,CS0MMA7HY -
. .
C0N,qTRU(!.1*:YN FFIE
I'm -0ob'.1 I 8.0oo
S664A16
I"Al -AN 0*t W FPT'
tol�1000_419_119
S24676
W=11WHIC1.1u.
Wl -000-111,4111 -000
1-01-004-420-600
SN'R.GNO MOTION (RF91
101 -CM -241 -WO
661
GRADING
101-00'423-(100
,r,8 (Itft,)
ARTiN Kiiii,1C PT,AC
70 I.,000 -25,54-Y)
the above- mention ed property-f6r inspection p,urpog'es.
RECEIPT DATE
ignature W n
(Ow er/Anp Date/
1, CONSTRUCTION ANP PLAN CHECK
LESS PRE TAID VVIS
DATE FINALED INSPECTOR
1.064637.00
$3,636.78
W N
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR,
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel 11171-1
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation 4�// 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath U, eel �OL
5
Final
Final 112�71
BLOCKWALL APPROVALS
POOLS -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 APPROVA S
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for. Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 7'
Encapsulation
Gas Piping
Gas Test 3711-l'!f 7
Appliances
Final
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 (Perin) Lv
COMMENTS: