0011-131 (SFD)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 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
Date ! f i d V1 Signature of Contractor (•� i �� - '" `
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). 1.
() I am exempt under Section , B&RC..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.
4'?) •I have and will maintain workers' compensation insurance, as required by
S6etion 3700 of the Labor Code, for the performance of the work for which this
peimit is. issued. My workers' compensation insurance carrier & policy no. are:
Cartier, Policy No.
(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.pr visions of Sectio'3700 of the Labor
Code, I spall forthwith comply with tt'ose,prolistons.
Date: f., , ^ Applicant—P jj.1f !'"1 � ,'' 3:,.
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.,,] 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 fog inssf` pec Ion purposes.
Signature (Owner/Agent) � a Date %i
Y _ PAW
i
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
lln4r i
JOB SITE
APN
ADDRESS ryn /7y
7&-M,078
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T1 3NI?MA AVE,
7161 MWIA AM
i2.iV.1:RME, CA 92504
fUVFR E Cfid 92504
.909)784-0840 Me. 5357
USE O��qqF PERMIT
W yw�gy(�� ry �yr�
\7 NVLP, 3'!'AS9 IL 3' 7�'iU.L'C c'F+.li`0G
FAMILY
M > WT 4:3, PLAN SCP, IPM11T 170&, NOT 114CLUDE W=r7: 'W. A,
O,f f POOL 151% Pi;.nUc•HWK ME ON fAUWPJP1j7:i ISSUANCE OCA faAME PfAN
7"a B
CUSTOM CO1d.s'i'RUCT10A1 21430.00 P
PORCHIP.t TIO ' 395.m SF .
0A1dAOMA"ORT (P) 10,564,40
FIRIKATM COST OF C 01V 117rRIUCIM014
204,f 77"
C0440TRUCTION M 1.01.000-415•:10t➢t8 s3,aPuo
X?t..AN C°kItCK F92 101-000-"139-318
h•
M1tMNXf�'�t'M.RM 101.000.421000 "MAD
L01Y.f4C TR11CA , VEM 101,000-420.00® a1mo.Ut
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PLi)Mf4YNO I FZ 1.01-000-419-000 OW50
M0140 MOT10i4 F < U.S11) 101-N. 0.241-.000 220.47
�
(11lAPINO TeFIE 101.000-4.. 3.000 $20.00
3'.l;?IVPLO F M1:IMM.0 FBPI $1,9iY m
A'03 IN }PUBLIC 1'yLACUI - RE11ZC 701 _000-25 5-000 $1.1.69
f'UA, TC iAL CO MUTJ'CTI 1`i AND MW L`'Hl"it;.`i�:
S3,600.41
1:x'14'9
$0.00
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RECEIPT
DATE i
BY
FII PECT R
1 ty1
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
A. ,y� /J
�� p(j/
Ducts
Slab Grade
!��`�
Return Air
Steel
Combustion Air
Roof Deck
_
W� Wq_
Exhaust Fans
O.K. to Wrap
S�j��/
F.A.U.
Framing/ ��v(/
_/
Compressor
Insulation
tom` ( 6�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
-�
��
Final
,lJ
Final
—
- — —�- —
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POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg, Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
_
—T -
Electric Final
Heater Final
Heater
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
/�/T!�(y �/�L
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
fff -
Final
- .
COMMENTS:
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)
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