9902-148 (SFD)N �
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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
1)9064}_5 !i 6;311100
lsbateSignature of Contractor 9
OWNER -BUILDER DECLARATION
I hsreby affirm under penalty of perjury that I am exempt from the Contractors
License Law for the.following reason:
( ) , I, as owner of the property, or my employees.with wages as their sole
comperisation,,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:
Policy No.
Carrier
SiTAT111 iUND WS -934230 Sn3n 0
(This section need' not be completed if the permit valuation is for $100.00 or less).
( ) 1 -certify that in the performance of the work for which this permit is issued,
I -shall hot 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 pJov slo S7
Date-.�>'4Zf S Applicant ✓ ��
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
i & 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
constryction, and hereby authorize representatives of this City to enter upon
ygntheBove-mentioned property for inspection purposes.
ature _(Owner/Agent)' Date�/-
PERMIT #
BUILDING PERMIT
"02A1.8
DATE VALUATION S2,14.941.81) LOT 15 TRACT X199-3
JOB SITE
ADDRESS SIMMS G.RA D TtLtiifE!$3ik, AV {a U E
APN 769-450-00r
OWNER
CONTRACTOR / DESIGNER / ENGINEER
D 11t'"f1n%14f7f: t f I"
Ill l f l'\!!.V.l l., 4' IS I,IV
"D 1"("' IAi'IF%?G�'F'AA'Y:AT'f'C t'hF1`,
tt/,lT tl LN 1511.. 1'P tf� .l l.�l.✓,
P.G.-BOX hiii
W25 Z UNi"v.EKRi r` DRiV :
LA 1; LAW.t1. CA 92:253
L'H(?hNIX Al 85034
(607)757- 1656 crif 14 49",
USE OF PERMIT \� t
S1�Itsi..}? PAf.�i.L1i' �9LiT�t.1.3�3ia.
LOT 35, PL1AW _M- titb - Px"aiWIT WES 1,R) C 314OL f 8 BL CK'e ALLS
QJt H{ 01,, Vf.AN f;I'I" N I21'-DUC RA) ; Y,d,, FQR MLIVI'1;1'1:.,6 ISSLMNC1_f Ml
SAME: PLAN .`Y.M.
CIUS'i`Ct-1C-QNSOMICa10N :1610.00 S
L'.:3Lct�-I/i}i'lIXY 140.00 SF
(1-AR.AMCi!•112.Ni)H.T 49s.vo 61.
PERMIT Pa E SUMMA Rpt
COQdS11XLrC111f0N l"�•, ).ti3-FH y4}8•(1U0 �.1,liJib.iifl
_P1.ANCHECKER, $214 C1'I
Suli:Ct tA.NICAL 'u1.: 1101 _000-'i t It _000 $105.00
ELEC" RIC=AL 1 Es 101-000.420.000 $1.`8 SI
P14UMB1140 1<'"Z l U l UO!J>A 19 ddt11) S180.50
;t'T►iC� ic1 Mn 9 It3N T.fvF - iCt<SZ'li 101 -OW -241-0 to .. _ . $i1..Q
GRADINQ 1'+M 101- 00,.423-000
iWf"<A5`Iw!'c TUi2 vEc 2.25-000.443-342 1.7'fh1130
AXI' IN PUBLIC PLAC,}:S a.E ESID 701•000-253-M
1 TJd.7'fYiFij, C'("13V;ti"i4i,Ij C_ f f. q i;i-iirf�, ,
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TOTAL PI -i MI T MEN OuC'l NOW
;823AS
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RECEIPT�1 (� j j—IDAT,E
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BY
DATE FINALED
INSPECTOR
) i f
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
O.K. to Wrap
CY-17 • 9 't L
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
7! 2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
1221 __21111,
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
Electric Final
Waste Lines
—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Fool 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:
I �.