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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
370768 03!31/2(
.Date !27J/Z2__—Signature of Contractor
OWNER -BUILDER DECLARATION
I herebyaffirmunder 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. ;.
(d)''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 STATE FUND Policy No. 229-99.00i3325
(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, 3ind agree that if I should become
subject to the workers' compensationpro Kiolof Section 3700 of the Labor
Code.1 s 211 fo flwith comply with S, G ins.
Date Applicanr
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 aan d State laws relating to the building
construction, and hereby authorize rep sentatives of this City to enter upon
the above-mentioned property for
ffoorr ins.. NT6 purposes.
,/`Signature (OwnedAgent)rd'�/�' � Date= (
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT tlW9 X32 TRACT
09/21n0C 561148165 10,11 21120
JOB SITE
ADDRESS 77-162 CALLE FLORA
APN
631.-771-010
OWNER
CONTRACTOR / DESIGNER / EN INFER
PAUL 114GEI A- WSONN
WLDON CONST UCTION Cil:
15 SYCAMORE RD
44-500 GRAND CANYON LME
ORINDA CA. 94.563
RA MDESE T CA .922610-3(
(76OP 76-4215 CnIA 5787
USE OF PERMIT
O• AI BUW_)-1NG
H ACK WAIL . Btu LI? it 9, 81'LF X 5, 163'Lf/ X• 6' & 96'L ]? xa
1101DER 31. ORCO SYSTEM,
6 �T, ti'iAE.L 163.001.:To
5 PT. WALL. 91.00 L,1?
4 FT. WALL, 20.60 LF
ESTMAUD COST OF COriSMM bd ION
6,246.65
F4hW-V FRE e`luhnv
CONSTRUCTION F4?L? 101.000.418.000 S96,t�0
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SUB-T01Ai CON :TeUCM0NAN1') PLAN' C%W.X`EE
$90.00
LESS ]PRE -!PATO FE M
$0.00
i
ip 1eCnAL i'KP" FEES DVIX NOW
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RECEIPT
DATE j ,�R 1 -
BY . ; (
DAT NALED
INSPECTOR
61
-3—
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
Steel-,
POOLS - SPAS
Set Backs
Footings
Bond Beam
_
b �%� -�
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Electric Bond
Main Drain
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
O.K. 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: r