0002-393 (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
13 11 V11JDate@� Signature of, Contractor !l�
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that Iam 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, ind.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. Professionals .
Code).
O I am exempt under Section' B&P.C. for this reason
Date - Signature of, Owner
WORKER'S COMPENSATION DECLARATION
Thereby affirm.,under-penalty'of'perjury one of the following declarations:
r( ), I have and will maintain a.certificate of consent to self -insure for wo'rke'rs'
compensation, -as provided for by Section 3700 of the Labor Code, for the
performance of the work for.which this permit is issued.
( ,a 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 : w Policy No. ,
(This section neednot 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
worker ;,compensation laws•of California, and agree that if I. should become
subject to the workers' compensat}on.provisions of Section 3700•of the Labor
C de, 1 tl forthwith comply with�those provisions
`Date:. -"Applicant /1 " 'ti c
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.
-. r 4
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'C_ ity to enter upon
the above-mentioned property I6r •n�specttionpiurposees.
Ignature (Owner/Agent) Dat •'=;i- ' Oo' .
w .
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'''BUILDING PERMIT PERM,',
DATE - `` VALUATION $3k.678.20 LOT i TRACT. 284114 '
;
�1c,t�
JOB SITE I5;•�
ADDRESS � 44iLA4C�1[.MI
APN
r*
�/iD,A-Yid-E!Y%g
OWNER
CONTRACTOR / DESIGNER / ENGINEER
%' n 11C"1'`♦"i7a�9+C /".�"!i' 'r,� rt- e r 'i -
6 11:4. o4 •..f'f {/•.a 1 lh! 1iA ,. 4 +.i
B AYl1t� A l i[ll S?�C.JY3°t'!`'('`.•i�d 95 rt�tT•'4'iT'66 9' (d-'
46 V 0'+•4. 4 A:. C •.i 4C,t WVAMA IrlLt1.+1..0 If+i.y AA �..,.
200 E. Wti,taHl NGrO t1 1i RI .. i;,100
200 E„WAn5l-1NG ON
AVE. 6'.100
9IsCIU fDiL-tt;.i! CA 92025
ESI.>ONDIDO
...CA 92:125 `
'
USE OF PERMIT
a
SINGLE .PA t' bXVk1LJN0, `.
SVC;- LOT .25 c L.kN_ 2-1 � PE,7WkiIT DOES NOT It�ic:�i:,UD BOCK WALLSe?f!'l'
'O 7t'✓o.PF:..AIN CHECK FFR. . AWDIa6310N FQI, AdUL'i IP1.'8 ISSUANCE'
OF :3AMF Pt,A�N '1'1'15:1?,
c to am C oNi 1"%ur-Mfai3 4,000.00 S.�'
aaUR[f;`i'A f'Ci , 7.98.09 Si+
c3tiEQ:ASil�JC;A�{.f�%:(r�l' %3b.i?!7 Sls,
IV
ESTIMM"ED COST OF CONSTIMCF10INT
3.26,61's .2 0
1;`ir;Itl�'A'� �16s.p>�iTt�Iv��h�
'.
• �• r ��
C0N8'1RtfC'9:'10N F - EE 401-0004M000
,•aNIr"EiEC,'a: RP, loll9 %x9694.
LILE'C 4'ftIOAL FEE 523i.26
lPLLfM61N(J Fl -:13 101000-419-000 $2.05.75
h•FRONc3 tb47 rF(AW PR - B$M 1101-000-241 41t1!} $ a k67
Wb,ir�9'1./FE34.��4^^"TE :q+ �V74.f
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(�l2/J�tla�i.f.�
/ ���edn�,Y.��yC9
i.�:�1 t1.i1w0+1.14 �.t lr1�1!i 1'.51C: dpiA 5'i l7itli443—*214 �.f•Ja+�.Vl�
�•''�'S1 "w� F ! R
ART PtJEii f C�:'PLAC&8 - RIP,' 71.1.1-1)00-23$�?�%i)
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.FN
SUR-'rA.i ,, ^t.?'C�( "r. 1_JI” 't(�N AND Px,}nN (yrs t :
f CCC s1.+i' PT"'-YL`I+C•
P.
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• JJ �� yy yy aa gg x g�� •pp��pp����pFryy� y, i yy��Yy ��((,, . 4•�4��,y
0,0.A.t'I'•Y.Ll t'9 i''YYl�;CD �'.,k.' iA.ki 'S 7V9.T.E 1��..71'V
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' U*66.i: 2
RECEIPT
DATE
BY'
FIN
SqcT t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
5
F.A.U.
Framing
Compressor
Insulatio
T
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Or
Final
Final
-
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Band
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPR VALS
Gas Test
Electric Final
Waste Lines
I 1zHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
p�
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)