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LICENSED CONTRACTOR DECLARATION
I hereby afflrm under penalty of perjury that I am licensed under provisions of
..eChapter'9 (commencing With Section 7000) of Division 3 of the Buslness.and
Professionals Code, and my License is In full force and effect.
license# Lic. Class_ ,,. xp. Date
Signature of Contractor /
OWNER -BUILDER DECLARATION 1
I hereby affirm under penalty of perjurythat I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
performanceof 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 Policy No.
(4B-p(i.3OTA F .Nl) r
(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 aorleer so as to becom subject to the
workers' compensation laws of Califomla, a agree4at if I s ould become
subject to the workers' compensation provisi s:of Section 37 0 of the Labor
Code, I shall fofth ith comply witI4 those pro sions.
Date: , 7l'i !r Applicant -'�
Warning: Failure to secure Workers' Compensation coverage is unlawful Jnd
shall subject an employer to criminal penalties and civil fines up to $100,006, in
addition to the cost of compensation, damages as provided for in Sectionv3706
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, indemnity
& 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, anci:State laws relating to the building
construction, and hereby authpl'Ize re ant lives of this City to enter upon
the above mentioned property for1nspection put
pose ,
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Signature (Owner/Agent) �f�f Data(/Vvy
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
0%11?4/2 : CA a 3(
JOB SITE
APN
ADDRESS
M -4 9A_
769-770-M3
OWNER
CONTRACTOR/DESIGNER/EN &NEER
LA Q'E-1110A tYRMA}2DS P
SPMY,. i ►�:!)C73J/k`f(°�SM(K'�11034
X10 }�1� 17 1 (1
79-295 S`�Y.'317t✓. 10 TJA QU1V,}•{3.CZT-
U,.Qui rik CSA 92253
1,k Q 3NTA, CA. 92231"
(760)771-1941 79W
USE OF PERMIT
600.1Y & OR.(..'O OARDIVN W.Fi LA..
07. "WAL,11 stw.00 11r
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meq, 5 (101AR, COk'kMV[PMION IWD PLA14 CHECK
$262.00
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ATOTAL"PKW-Irr.FEES.FdS
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$Sll�i�rO )
RECEIPTAT
Al r,{
BX� ATE FINALED
INSPECTOR
) ��
NSPECTM RECORD
oORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDWG APPROVALS
6i ECHANCAL 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
13, LOC eWA' LL A -F PROVAL S
FOOLS e SPAS
Steel
Set Lucks
Electric Bond
Footings
Main Drain
Bons) Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final _
EPLU' UMC nNG APPROVALS
Gas Piping
Gas
sTesElectric 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
Sealer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice.(Gas)
ELL EC7i=AL 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)