9903-168 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C,'.�ipter-�(,'"ommencing 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
,pate � � ��, � � Signature of Contractor
V OWNER -BUILDER DECLARA ION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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).
( ). f arh exempt under Section B&P.C. for th -eason
Date f/z'/.:4w Signature of Owner ` a ✓
!e _ % !�
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.
( j 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.
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith' comply with those provisions.
Date: ADDlicant
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.
4
1. Each person upon whose behalf this application is made & each person at+j�
whose request and for whose benefit work is performed under or pursuant toe"
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 ifs
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 representatives„of this City to enter upon
the a 6ve-mentioned property for inspectifon%purposes.
7 ;t
,!
,Signature (Owner/Agent) u'” / �✓ Date'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT "03-168 TRACT '
3/H"9 $1i566.�
JOB SITE
ADDRESS 51-505 AVM10A 1MR.Z> ERA
APN
- -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
F 1. FOX
F. J, 'FOX
5i-505 AVENIt3A HER R.ER.A
51-505 AWNWA HERRERA
LA 4UINTA. CA 922.,53
LA QUI;NTA - CA 922.53
USE OF PERMIT
GENERAL-RULi9lie G
0Ai2 -WN WALLS - 54 L F_ X 9 & iO L. . X Y. MYSTANDARD&
QXfE 13 A"'Q HUNG FITTED.
G ds'r. 1kaL 51.00 LF
5 FT. WALL 10.00 LF
D:"4 MATEM COST T C?F CO NST.411"UuTION
0
1,%-6.50
PE.44i.IT FEE sTJmm' 'A tV
CCft. 't'ItUCfrvtd .Ffig 101-000-418-000 S-1-7.00
f�'ytf
R- EOTA), € OMP`I UC;rION ANI) PLAN CBECK
417M
t� s�� TAITFs
$0,00
a7TAd:.PERA41T 1'+'91"f.8 DU E ( ONY
v
F.RECE15%
DATE 7',
1 BY /j'
DATE FINALED
INSPECTOR
INSPECTION RECORD
�- OPERATION DATE . INSPECTOR
BUILDING APPROVALS
set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION + DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.L
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Bond Beam 'a%_
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Ptbg. 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
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.L
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)