0108-287 (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
763187 B �� 1�' 5ri1103
Dater•_ - �l. ,Signature of Contractor
OWNER -BUILDER DECLARATION
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.
U.1 have and will maintain workers' compensation insurance, as required by
Secfion 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.
ZD41TH MM CO.
(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 agreeythat if I should become
subject to the workers' compensation provisions ofXSection 3700 of the Labor
Code, shall forthwith comply yvith those,:pro�isl9s.
Date: ;� '!�.. t.' Applicc3nt
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.
r
Signature (Owner/Agent)" '/-µ Dates --. r
j UILDING PERMIT PERMIT#
DATEr/•,r VALUATION LOT Uti9-27 TRACT
`
!
�(;' 7' %, C.- O'r7.�i aAg F{T{9s67f1' S 26444
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEERQQ
�, y�priyT,,.tT U ����7 L, �t♦`p�r�7 /
'�F'"noafx/.Stl.bi.91:.�\J3L.J�' 11�1m., t1
�� 4:.,�aT•
•gyp T�9 t...t, r�vag�� Its
31-m�.e�YP.TiV - ItsSoR c'i.7iY...xKtV.flSAdl4fes, raa
2110.Y� Wm- fWmTr0 .q.K':.VF,:nx 100
200 , WAMM TON AVE.. 0100
lf�"a~%)kifl�J�L7t� CA 92025
.F43C;tal`9 MO CA 92023
(760)8-#9-&238 MVP 5413
a
USE OF PERMIT
6'ilNGLE FAW3. Y MWOU,1340
FO w PLAN 2•2C,, WT 5I. PER'to�iCl' ft 13 I+IM F13C'r. Do Pool
ALOC K `VALLA OR PRNEWAY-'APPROACH
np
WAU(
1
C17s�TOld C6140TA318t MON 311796100 3x
1%O1tC}:i4�=:F4.TIO W&00.101 S0' CITY
F LA QUINTA
01ARAMMARPO?cT "Y31100 OF FIN
NCE DEPT.
R91.7L'C`A t°09r OP C:OM.' fiRUMI€ N
:420: mxb
CONSTRUCTION FES 191--000-410-000 $1,413.00
9
PLAN CHMIX PFIE 101-000-4"-318 $28639
1>�i1���A�11C711,,�t�� 'P(i1-c3C1t1�21�Uo0 �111.As�
f2,1+,C1'RICAL Mr. 101- -420-000
PLU111111110 "19 1.01.000-419.000 32A5,"73
STRONG M(Y 1ON FIM • R SID 101-000-241-000
C':11Z.A.17YNO FFK 109.000-423.000
3NIdRA•S`FRUC'1UR.& 22,5-000-44.3-142 $1,5m.00
ART IN PUBLIC. PLACE* -1(.1!:411:.2 0.000.445.3N $301,47
1:M.«`turAL C:`0+MMUC."'i ON, M.DPLM, CVH1 IX
$4,501.30
LESS 1''. E—PAOD MS
$0.00
1'0TAL/ ,P13.1'MT xF0751 DIS' NOW
i�,W�s631.3E➢
i
RECEIPT
DATE,
BY
DAT FI E ^/
INSPEC
e.-
f�--
INSPECTION RECORD
OPERATION
DATE .
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings `
Slab Grade
!"
��y%Ducts
�`62,
Underground Ducts
Return Air
/ n
Steel_
Roof Deck
O.K. to Wrap
_
r � 6
p� �, `�%
��-
Combustion Air
Exhaust Fans
F.A.U.-
_O( j/
r
Framing
_ (� GQO
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
� �
Final
Final
OO�`-�Y/'
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
_
,cam i 6
p
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
�/3/ Ji
Encapsulation
Gas Piping
Gas Test
Appliances
'� 7
Final
COMMENTS:
(1 /d/ /-,1
1110, 44
Final
Utility Notice (Gas)
—EH—
60v
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures Ole
Main Service �.
Sub Panels n1
Exterior Receptacles
G.F.I.
y
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)