0306-436 (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
79 59 B luc
✓Date"•� -�' Signature of Contractor f ' `
OWNER -BUILDER DECLARATIO �
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). r
(,) lam exempt under Section , B&P.C. for this reason r�
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, fo`r` the
pe�,�rfo,rance of the work for which this permit is issued. , I V,
Y'�,�11m' ' have and will maintain workers' compensation insurance, as required by.
Section 3700 of.the4Labor Code, for the performance of the work for which this
permit is issued My workers' compensation insurance carrier & policy no. are:
Carrier' - STATE ('OND Policy No. 229-002M6-
e .
(This `section need not be completed if the permit valuation is for $100.00 or less).
(') 1 certify that iii 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 r
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
ode, I -sl fort�ivgith comply withthe provislo`ns.
ate �- j � Applicant -A syr �i s e`il
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, and State laws relating to the building
construction, and hereby authorize rep respnfatives'%f this City to enter upon
the above-mentioned property for i spectiorrpurposes.
'ignature (Owner/Agent- � //f �. � �/gyp-- Date
PERMIT #
", BUILDING PERMIT
DATE• t».* • : r VALUATION ` LOT TRACT
JOB SITE APN
ADDRESS 51,-00 aA`Vr"A I))=. A _
OWNER
CARL YE N=om
51-045 AV N DA.L3A i A
La QUTlrrA ,
USE OF PERMIT
64 I. F. 6` RION CAMIJEN WAIJ,
t)
6 IST, if1:rSIA,
CONTRACTOR/DESIGNER/ENGINEER
44-306 MSQUITF- DR
92253 ,' UIN WELLS CA 92210
(760)773-4,487 CBLd# 6645
S'YSTE14)
F5:1�7C 1� con "Y G*o"6"L'Ir,•LYC7Sl'3i�
L''fit R3.t�])CT' "VRE StT1127F,rliAirt.Y r
CONSTRUCTION RE 101_010$418-000 $37.00
'- ' e" Oat Rk�P PLAW t L C`I� $37.00
IMS PPM -PAID P .EI $0100
Jl�id b e� TA," . annis.�MIMSDt�EsYc.>W "7.00
CITY OF L.4 QUNXTA
RECEIPT IDATE BYI DgTE F�yA�ED O G/ I INSPE T(�Fy �/
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
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
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs - ,
Footings - O Gfoo—/
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Seger Connection
Encapsulation
Gas Piping
Gas Test
Appliances
-
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)
Building
Address
Owner
I
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Mailing /
Address �.
City lZip., ITel.
Contractor
Address
City v`
Zip
Tel.
State Lic.
& Classif.
City
Lic. #
Arch., Engr.,
Designer
Address
Tel.
Cityl (Zip (State
// Lic. q
I hereby affirm that/.Am lice s �f visions o Chapter comm
70pp) of Division3 �'r%i /�affd y lic a is
effect. / '�i✓,�/� f
I hereby affirm that I am exempt from the Contddctor's License Law for the following
reason: (Sec. 7031.5,Susiness and Professions Code: Any city or County which reouires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
C 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees.
provided that such improvements are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
C 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts dor
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
C.1 am exempt under Sec. B. & P.C. for this reason
Date owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
C Copy is filed with the city. u Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S100) valuation
or less.)
1 certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: 8, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
.DING: TYPE CONST. OCC. GRP.
Number
II Description %/fJ
,ct Description /C.�3773-R 2 441: 0AM-S
IF
ZONE:
BY:
Minimum Setback
Distances:
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Estimated Valuation
Validated by:
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.L
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation: