9004-033 (RPL)H
V U)
C
LG
O =) ch
Lf)
h Ill
Q
Z
(0O�
C) CD
W W
ra
D7
Z
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of peryury'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 forceand effect.
Cleanse # Lic. Class Exp. Date
Date. Signature of Contracto
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).
O 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 My-4W..orkers' compensation insurance: cariibil,%iOdicy no. are:
Carrier Policy No.
(This section need not:be completed If the permit valuation is for $100.00 or less).
O I certify that in the performance of'the work for which this permit is issued,
I shall not employ any person in any anner so as to become subject to the
workers' compensation laws of California, and agree, that if I should become
subject to the workers' compensation pr9millo " of 3700 of the Labor
Code, I shall forthwith comply with tho 0
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject:an,employer to criminal penalties and civil fines up:to $100,000„in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and' restrictions set forth on his
application.
1. Each. person upon whose behalf this application is made & each,person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as,.a result of this applicaton agreesto, & shall, indemnify
`& hold harmless the City of La Quinta,'its officers, agents.and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance. of such
permit, or cessation of work for 180 days will subject permit to cancellation.
Icertify that I have read this application and state that the above information is
correct:. I agree'to comply with all City, and State laws relating to the building
construction, and hereby authorize. representatives of this City to enter upon
the above-mentioned property f r' ctio
PA -es.
:Signature (Owner/Agent) Date /017
f
PERMIT # CONTROL #
BUILDING PERMIT
,af+$..�k:+t 3077
DATE VALUATION44t►I+ i�l LOT TRACT
JOB SITE
ADDRESS 44-77,50Iw. �Gt1it�.,�li:�� {�+�.
APN �rf1�F•�.f{-{9x.1 .
OWNER
CONTRACTOR/DESIGNER/ENGINEER
g:Un, ern, �y �tf ''ni t t)rwet '7.
.,I.:.�;ar, Irtt�/.�.s:.<.,.,.�tto1,.,.,1�,4 ,;•.t.,-
t ""0 nrt�lL1 K
..1/� .I�.t4 u.4
Yr/ t`;.
.147.4) i-hll{. ANI y 1]"K
•1337S tvi;A ISDN 5 i'
1,A QUINTA i -;A, 1?2253
INDICI l,_'A 1►22,12
i ci i'J 0,17.5959 C B I. H 1151
USEOF PERMIT
t'i :+i',1t, c11�i.irl:[t a't1
D
VQ(_%i. ATAY k .81AA - 14.iAW.Q0 1
4
&s 1! imik 11 m cos r Gki' L'ONiS'TRUCT.tON
PLAN '04E t: Ffal HW -OW -439-311 549.45
FFE 101 -OW -X118-00, 153,fA
NIL, 14,MJICALFEC -••fCK.)L 101-000-4I21-00 $2.4,00
�
1 t :1'Idl�;tii. FE- -- 1'1001, 1U1 Uix!-Yi l)-UtfG $45,,00
CD
PlAiML I NQ FEE. -_ P00t.. I m .-ow-419.000 -.2 -,.Off
I� ” M
D 11:Z
CL
Cc
S`UD TCYrAl, CC??�S IRL!C" 10N AND KAM, CHIECK
S348,45
USS PRE-PAIr1.CEES
...$0.00
•1'fiTAIi., >F"1+:ltNi1►T F EMS 1-114, N01V
smx.cs .;
RECEIPT
DATE
BY
DATE:FINALED
INSPECTOR
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover Of
Equipment Location
Underground Electric
Underground PI . 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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
7 F7
Gas Test
Appliances
foal
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
MENTS:
• b
-