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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
Date Signature of
Contractor
Signature
DE,6LARATION
I hereby affirm under penalty of perjury tfiat 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 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 Policy No.
Z ENti11111143 CX1
ZD421 fi(i142
(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 h h411 f6rt, with comply with those provisions.
Date: , Applicant—
Warning/Failure
pplicant WarningFailure to secure Workers' ComQe ation overage is unlawful, and
shall subject an employer to criminal penalties and civ, `ffYf uMM, 0,000, in
addition to the cost of compensatiorf 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
cyyhstruction, and hereby authorize representatives of this City to enter. upon
fie above-mentioned propertyf r itispectip-P.Purposes.
Signature (Owner/Agent). Date !Z
BUILDINGPERMIT PERMIT# CONTROL#
97115.11x3 3
I
��
DATE TRACT ,2515
VALUATION LOT T�
{ S 124.691.40
ADDRESS 445-414 C)E.SKR VIE"I COURT JOB SITE
APN 6".331 -on
OWNER
CONTRACTOR / DESIGNER / ENGINEER
:'i1., ��:�Sr1C"
t'-I?"vrl iRy 1rkywEt.i. Cts :1i u.Nirmiss
I S3, S ii SN W200
151-6 SO. "D" 51'RE MI, grp. #200
SAN BERNARDIN(.t VA 02409
SAN BERNARDINO CA 92408
(�t191181-6007 (_B1,# 2120
USE OF PERMIT
N111 1
it -11A/, 1:11.AN 5Xilk, Pi, AN -_'lik:K ki& RU) )CEU 6Y 7 0R NILA. V]PIA'.
ISNI r1i (W NAME. PLAN INPH
Ttttl�'!' (X)NS I72I1(:I'ION ;,073.003F
63-00 3F
0ARA01-;/C ARP0R'1' 576 04) 3F
RNTIhMATED (',T)ST OF C'ONsTRUCHON
124,691.40
1 CHA11.1" FEE E SUMMARN
PLANC1iFCK FE.F. 101-000-419-319 $1530
r'0N.TfRI[I C7T0N 11iF i01 (If)t; 41R-1104? 37.n.W
NIE(IIANICVU. F GH 101-004421-M S7si i>U
Isl.isCTRICAi. H1s1S 11014**-420-WU
PLUMBING HE' 101 -(i)0 -419-0(K) $Ih7.24
3Tc?NO W)Ti0N ►t _ RF311) 10i -WO -241-000 SI^,47
GRAIANts ):ri* 101-000-123-000 Sro.W
INF'12AN` RU( -T )REF01' 215-CK)0-443-342 $Z'M.70
ART IN PUBLICS PLACES - RF:S11' 7014M.255-d>t10
W ;t 'cr:�I�Al.. c�c:�NS"41rt)�1"IC?N AND PI AN CIII-�K
S14,140 16
LESS l'il'y -1 AJD1 FEES
$0 W
30- r i TA -1e { i' RU l' FERS 011E NOW
54,1140.36
RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
r. 3
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel A
Combustion Air
Roof Deck 1.0p X
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath _#z
Final
Final
POOLS - SPAS
BLOCKWALL AP ROVALS
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 Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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)