0211-028 (SFD)LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that I am licensed under provisions of;
°U) Chapter 9 (commencing with Section 7000) of Division 3 of the Business and..,
Professionals Code, and my License is in full force
w and effect. - ,
C.,) License r -ic.. Class _ Exp. Date3 f^
LO
LUr
Z Date, /,.2i" e-1 Signature of Contractorf t {•r r"�" "'°"
„ OWNER -BUILDER DECLARATION ' F
I hereby affirm under penalty of perjury that I am exempt from the, Contractor's
License Law forithe 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
t 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')ssged i1hy,workers' compensation insurance,gy�8q�plicy no. are:
Carrier Policy No.
(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 toAhe workers' compensation provisions of Section 3700 f the Labor -
Code, I shall forthwith comply with those provision
Date: a� . r ty_ .�,� Applicant //f/� c.a... rt 7�,t .<.:4
-,—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.
I 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.
y�
Signature (Owner/Agent) o�r �.e d. �x �r �0. [, Date
_BUILDING: PERMIT PERMIT# +—r'
�V
DATE ; I VALUATION �` LOT r TRACT
,
i
JOB SITE $q - a WH184L ? F,
APN f.:
ADDRESS
4
OWNER-
CONTRACTOR/DESIGNER/EN (NEER
CIZV LA Q`(;U:[Y42TA U :; P
MV T., A QUNIT',rti110 U1,
2100 ;t?, WI.`7k11NU 0111 ANE,
2001Z VWPAIII-MyroN AVX
Cy 2 3 �3 CA 92023
i; SCO l3"r O UK 9.20.21
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USE. 4'EY'waG' A�'d�11�!dLr J. i✓\-'Y1:�faT.LLY I.i'
POWSPA Dfit?VOWAYAPPR£kAC
CUSTOM COV81'RUCTION MOP,00 SF
P0JZCH1Pt%.T10 749.00 SF
C° �,A.10EiCxMA.T 1'ORT 60100 SP
0 (1109r OF MRaS']('[cOC'"11011
'•�y��p,.•�,
z?,. -;99.66
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!! •{� �yy'yy����(V yy9� Q (Ep�y;rMA1121
1�.8:4�T:1IS1[�y $J.� i�i.iStldS��.MR,A48
CONSTRUCTION RE, 103 -OW-41 8-000 S3,5127.00
K. W cfacK ffm 101-000-439-:318 $1,07634
.mr-c;; "%trw.., mu, 101-000-421-1000. P ASO
E7.,WTY.UCJ1Jo Cr'A -STt 04'.',&-60 f Sb45.R9
°2;7RCYA1U MC fX-N. YKE, o° l,.w,-9!D S $29.46
MAMHO ?V17 101 -000,423-000 060
e<JENEWPER.IMPACT FRE
.ART T'i;3 PUBLIC .PT..11.f� ''-1€iAIT 270400.445-000 $236.50
41 :4
3 .:rte:. i?'
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13- ` . CO i` tTC ffK�W,*J131�1wi.0 C [i 4'
£;
NOV 19 2081 � s 1 v0W
WYOFiLAQUINTA . f
q�,�.: W73
R�'��OF
{
y
RECEIPT
DATE
BY f
DA IN D
CISPECTOR ;;
4:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings "�--A-42–
Slab Grade
_
/ 2a/q�
Underground Ducts /
Ducts _ _
Return Air
Steel
Roof Deck
O.K. to Wrap
a �%" _ /l��
Combustion Air _
Exhaust Fans A
F.A.U.
/ �
Framing
Insulation
-- ./(,(jCybQp�
p�� ,
yl9lbr
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
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
Gas Piping ,
PLUMBING APPROVALS
Gas Test
Waste Lines
_
j�Q 6
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/fj�
6
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
��i S IIIglo/ 6
Utility Notice (Gas)
_
114
k
/-7 �o 6
ELECTRICAL AP ROVS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
_
Lr_J
Main Service
i
Sub Panels
Exterior Receptacles
G.F.I.
\ 1\
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
_