0308-256 (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 '
'723102 D 1VIC %: 9/30/04
Date % a Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License taw 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 n;t:xs 3ie p11nic.1NSU Policy No. X1OD30400
J (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
3 Code, I shall forthwith comply with those provisions.
Date • %/� . G'?� Applicant
s
Warning: Failure to secure WorkersCompensation 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 representative's of this City to enter upon
the above-mentioned property for inspection purposes.
�.-Signature (Owner/Agent) A'.ff-,✓ r w•% Date _/ 'fes t
BUILDING PERMIT PERMIT#
DATE VALUATION�,q�/'� LOT TRACT
sdh1AU .�—l0 13 4052.1-1.
JOB SITE ' -"�
ADDRESS 18-416 VIA FAVION
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1.1�1t�P.t�C LAiJJ c32'` GT f�iyi%��T�1tiTIA
LZNWAR R'IO.hiL'S OF1VYDRkA
8-401 C M4 01TWAY 111.
78-491 C.1DCHPArAY ? 1 1
LA+CGU"1, A CA 922S3
Z.7 CA 92253
.-
�Qt�•7JpI3rrkly,
q 11
Y l tiri J F 1• �1 d i� 1 �vAU- .ax°r 34
USE OF PERMIT
S'.472 . LOT IN PLAN 4A. PERMIT GOES NOT DICLUDE 81.063K UTiALI 3,
Pool, °15.x, OIC ARlV 1rAY APPROACT4 "i5 % ReDUt:'1.`rf; M TO PLAW CHECK
FEE W0T6. MUT..'f.'il'°I,,E TSS21A CE OF SAME TYPE
T..1LKT CONSTMICTM4 : 760.00 SF
PORCH&ATIO M, Do SP
` G.MME C.A1iPORT X12.5.00 Of -
MdUff ET',' STUAVIAR:i
b:C1NSTRUCTION FEE. 1 01.00 0.418.10100 $956.59 '
??LKH C 11PCK P'liZ 101.-000-439438 $1.'1$. et
VIE, C°I$E' LAICAL F,Cq Td 1016.000.421.000 $60.00
ELFX.TRICALP72 101••000-420-000
PLAYWIDINQ FI�, 101-000-419-000 5160.00
STRONG MOTION FEE, RF31D 201-000-241-000 $16.18
MArxKO FlU 101-000-473-000 $1S.00
SL7D-:COTALl7'C11011.)i'ANDP:CAX C}A`CK,992,6.79
LE:�+. S PRE -PAID A� M3 $0,00J
Y�!�
A J .0 .I:aJ.`t.S?A:. r L' cL.Rs.1.9 DIFF. NOW
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RECEIP IL QI�:Y',
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IN PECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
_
Forms & Footings /� _��-; �fjr
Slab Grade
Ducts _
Return Air
_ _
Steel _ _ _
Roof Deck / _
O.K.'to Wrap
Combustion Air
aust Fans
F.A.U.
_ _ _ _
Framing -
Compressor
_ _ m
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 �
BLOCKW LL APPROVALS
—final _
POOLS -SPAS
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 APP OVALS
Gas Test
Electric Final
Waste Lines
Heater 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
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) —
ELECTRICAL APPR VALS
Temp. Power Pole
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fixtures 1111 )r
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) . y