0108-286 (SFD)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
-763 167 :13
Date 1- "� Signature of Contractor !' f /
Y
OWNER-BUILDER DECUARATIO
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 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.
d. 1 have and will maintain workers' compensation insurance, as required by'
Stiction 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:
Cartier Policy No.
MAIM IM I S, MLY042314506
(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 agr'e'e' that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit tKose•provisions.
Date:.- 21 w 5/ Applicant--%._,,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer torcriminal 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/Agent) T, /� . r Date
% BUILDING PERMIT PERMIT#
'TRACT
DATE �•; � VALUATION LOT f)1t}E1M,'21'�5
;I�41tiIR,�'f3tt.7'C3 52 2&24^1
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER /IEE�Ny/IINEEER
y{�[ y �inr Yq� yam( y
\yynY�Fqy'>��;yR���i.,,YALg�gqIl�ppLlt�S�.13''�yb��d,,'yy4.•��f�S}},��u� �Yi�:nnA,,iyy}J.�yy�)).LA��g.+.r��
/y ��(p�}j1p+�j�ry �y
B�YFVd/ig1��fVygA�ApS,1�VYL�iy�J:,Syif:.•�I�rJSi.:1 Cg��i+Myl�Y7bL/}.•RVAJ.I.Ft MCI
yd`,I�
fr00 .I:n �YZ"4A71;�d.L� VJ S�i4� S�.YS+n Y Hc�.11:r 3 V6,.'
200 7_n VYA'• 0111 "4.YT N )� 7 E W j 00
COMADO CA 92025
ESCOMID0 CA _92025
(760)09-8238 031.4 5413
USE OF PERMIT
ONO, E, FAWLY'DWEIMG
37D , PILAN 1,19, LOT 52. p'Eli'NIT DOES NOT INC -L UM PO'T'i+l, A
BLOCK 1�i`AILI9 OR f�k11�'EWAY.f>PI�itOACH
U
CUSTOM C' iYMiTRFiCTJ.014.mop a? CITY OFQUINTA
9 ZUU1
I'C'titGli/PAX10 394.00 e3F FINANCE
DEPT.
0AItAOUCA RPORT 689,0019F
�•
c
CONSTRUCTION FIM 101-000.4113-000 $1,A3,00
PLAN C.HYCK YFIK 101-000-439-318 52724.37
MECHANICAL FEE 101.000-421.000 $:11.6,0+
N1XP_TAICIaAl,PEE 101 -000 -420 -MO �191.SiS
Pl ndytrHo bdi?,'t? 101-000.419.000 $210,50
'1TRONLI MOTION IrFZ - IIIA ID 101--000-241-ON W.02
GRAS31140 FRE 301.000-+123-000 13X0
0MY211,011.SR IMPACT ITY, �1,90'i.04
.SPT IN PkiH .IC PLACES - 3-tl;:k1I1; 2M000-441.000 MOM
01JPb-TOTAL COMLdp.?M1UKANYI3�� 1`��'�����.ggA+W f.IHEC:K
$4,143.16
y �y �
S:C"im mrs-PAl1.) J. ti.i;u.T:.O.�
lR 0.00
13110TAL X'MMA IMES DVE NOW
$4,343,16
RECEIPT
DATE -f G f �� /
BY
DTE FIL4ALE
SPEC
/'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _ _
Forms & FootingsA
Underground Ducts
Ducts
_
Slab Grade
Return Air
Steel _ _
Roof Deck
Combustion Air
Exhaust Fans
_
O.K. to Wrap /-� /� aQppq/
F.A.U.
Framing �9 ��
Insulation ///i �,-��.L��
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall _
Exterior Lath
Drywall - Int. Lath
Final S�
Final
_
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines %/ 04v
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral "�
Pool Cover
Sewer Connection /�l6'L (fir
Encapsulation
Gas Piping _
Gas Test ���— • /
.OL1D_
Appliances
Final
Final
COMMENTS:
Utility Notice (Gas)Q�a�..
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
UtilityNotice (Perm) %