0106-399 (BLCK)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
� 4 y v
Date Signature of Contrraeto� _ �' "�-
/
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
Cc I hereby affirm under penalty of perjury one of the following declarations: .
p ( ) I have and will maintain a certificate of consent to self -insure for workers'
�L- compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
U(r) 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
Fa- permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
I 5 1 . Z'li'+&.a£i tat �lSS�J�'°a•1+2
:d
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
Code, I shall forthwith comply with those provisions.
r / Date /7Z. _ Applicant J {
C Warn`ing. Failure"to secure`Workers'Comperisaton coverage is unlawful and
E shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 37061
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, .& shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work ,is not commenced within 180 days .from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
j correct. I agree to comply with all City, and State laws relating to the building
/ construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) r Jl'-� iJ !-� Date 0
BUILDING PERMIT PERMIT#
DATE //f VALUATION LOT O'1Of Qp TRACT
f' Elsa; r 219tD `:3 24 ;Ei 211`23
JOB SITE
APN
ADDRESS '
53-540 AVI;i'eIDA •3i':O.J.-
774-434-W.1
OWNER
CONTRACTOR/DESIGNER/ENGINEER
4J1yrgMI&yBDp SCE'M&yipN
AO.TdPy ,J'
C'..7,i S YC•tak•.'tb,fO.[7
1$''9 MITI 1FALM 011RCTM
81.900 AMM, 5 030
PAW '(,3R�i't T CA 92211
DW10 CA 92,201
( 60 772w2s4's C.W. 1,451
USE OF PERMIT
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FINANCE OCpT
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RECEIPT
DATEf
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD- '
r 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
F.A.U.
Framing
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
BLOCKWALL APPROVALS
POOLS -SPAS,
Steel
Set Backs �iZ 3 -.Of 5?
Footings
Electric Bond
Main Drain
Bond Beam S7
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
4�
V
Bin #
City.of La Quin W
Building 8r Safety Division.
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 77.7-7012
F Building Permit Application and Tracking Sheet
Permit #
6
Project Address: a V1- Lta
Owner's Name:
A. P. Number:
Address:
Legal Description:
Contractor:�-A (01�J
Address:
City, ST. Zip:
Telephone:
Project Description:
City, ST, Zip:
AJ W r, 1, L
Telephone:
.....................
...............
.................
...... . ... ......
.......... .............
............
State Lic.
City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone: T51
*X
StateLic. 0: X. ..........
. . ...... .............
Name of Contact Person:
C istruction Type: Occup incy:
Project type (circle one): New' Add'n Alter Repair Demo
Sq. Ft.:'T# Stories: # Units:
Telephone # of Contact Person:
Estimated Value of Project::.
APPLICANT: DO NOT WRITE BELOW THIS LINE
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural CaIcs.
Reviewed, ready for corrections
FPI1n Check Deposit
Truss CaIcs.
Called Contact Person
Plan Check Balance
Title 24 CaIcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"' Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P,
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees