9812-007 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
t- 'k Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
r- aU i.
W 7.14188 Y3
oZO Date •� , /� Zig of Contractorg
U C:) r OWNER -BUILDER DECLARATION�5-
W LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
ce) () I am exempt under Section B&P.C. for this reason
NDate Signature of Owner
rn
U Q 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
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 ' �yY T pp//yy* y7 Policy No.
WAp ��.
µrC 5114€SGS-tv
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shalliforthviith comply wiitb those?provisions.
Dater /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 enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agerti Date`-
t '
BUILDING PERMIT PERMIT#
�!iFl
712
2-7
DATE VALUATION LOT TRACT
1$7,5".40?789y
1 -) - I-) ''ICI
JOB SITE ✓
APN
ADDRESS 1iW25 USER SST E AN -1 i3RiIdM'".
"314 005
OWNER
CONTRACTOR/ DESIGNER / ENGINEER
'w'ry�rtiiGh�`7 ..�T�V�� (�.
I;
L'iq.1\ Cfti�L ��
P4MEc
1535 SO, "D" S 17UtRET, M. A200
1535 SO. "D" a f R.EU, STE. #200
SAN BER.NARDINO C:A. 92408
SAN 8FANE\MNO CES 92408
(9t)+3)"iRi.-{,(1(y7 C;}Si,#i 2120
USE OF PERMIT
KESIlMENTIAL ADDITION
CHANGE DG, k9Y PLAN 3 TO PLAN 3:L DZiR; NG CONSTRUCTION (ADDS
218 S.F.):PLAN CHECK FFF.I.tUDUCW 75"l0FOR-NAILTIPLIS ISSUANCE
OF 3AME PLAN TYPE
TRAO x' 0014. 'Ti..UCriOAi
.itN.'t S. �1.1�0IX 9;..6✓ MST OF; CO VSTA1.IJC $.YON
�i,�lY�tl^.VII
ilb.hRMiTFE L'SUii8.i`6+ildaFfA
0iNS'&IZt)'C ION FEE 101•-000-41Ft-000 $36.00
FIT, AWPIIT 7K,Tt?T sS)6,-hilt? d�G 11ji $704
NIEC14 NICAL. MI. 101-0V0-iGi-OL`0
1.1LECT t"t1CAG f t 4 101 -000-42"00 $3.27
S'.i'fit 1W) k10T ION'F& -,RE811) IN -000w241-000
f:t�I sdaftfC;'f Etfti 7> ti '�'i_f1(2f1at}d�4:;iA'1 $170.20
,9 X93-7RY1*,.A1, C ONO MLI(MON SAND KAN l;HECK
LESS ME-PA;1C) FEE$
X'110
TOTAL PCRM1 .kT C&% 0UF, NOW.
$2117
1r�
RECEIPT •
DATEBY
},IT
DATE FINALED
INSPECTOR
�.
r,
)
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 APPROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS
Shower Pans
Sewer Lateral
Sewer Connection
Gas Pipina
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)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
POOLS = SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test .
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Covei
Encapsulation
COMMENTS: