0401-308 (BLCK)LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W `-tP7ofessionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp Date
LLJ
r- Z r- Date /-�''" + -� ! Signature of Cont ctory
o 0 / —
~ (D OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
c•') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
d Q WORKER'S COMPENSATION DECLARATION
p ZCc I hereby affirm under penalty of perjury one of the following declarations:
Lo F- p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W l= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q (� ( ) I have and will maintain workers' compensation insurance, as required by
O U ,;Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
Ct Z Carrier Policy No.
ob NATIONAL IJN1014 16.1433
J (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
3 subject to the workers' compensation provisions of Section of the Labor
Cod le shall forthwith comply with those provisions.
'
Date: -• i i ('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 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 statethat 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 for inspection -purposes.
Signature (Owner/Agent,) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0401-3W TRACT
SI'Smoo 44 3002
sj
JOB SITE
APN
ADDRESS S] -61 v JJE"S.h-"F�" T WTLLOW DRIVIi
OWNER
CONTRACTOR / DESIGNER / EN (NEER
3-11F.A I.,A. Qt.11VrA.I.1X �
Fii TEA..LA. QUIN-CA LLC
61260 AVEN(JE'62
81260 AVEbTUF 62
1. A Qt71NfA CA 92253
IA Q%iWirA CA 92253
(7(i0)77'1.60w CBT. # TW
USE OF PERMIT
GII)E;12.A1u I�UTi.T31Ni1
60 LF. 6' 3f.CICK WALT, 01ZCO 8YS'T h4
b FF. . WALL 60.00 LF
Eb"7'Z IA:4 W CCAS' OF CONS.�7,a if Uhl
C"i?'!'1VRt1MON F12 101.000-418.000 X33 a0
s
!1
:3T.),f1-TOTAL CC+N.a i *R111MION AN0 1'L.,01 C;S•.Ir±:C'IC
$35.00
- TY3 s PRE -PAM FM
$0,00
'FMAL JIF—RI41T FEES W- . NOW
vl!wo
RECEIPT
DATE
BY
I D E INAL
IN R
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
nnM,all _ Int I ath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts I
Return Air I
Combustion Air
Exhaust Fans j
F.A.U. j
Compressor
Vents i
Grills I
Fans & Controls
Condensate Lines
j
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond ,
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location;x '
Underground Electric
Underground Plbg. Test
Final
Gas Piping I
PLUMBIN A PROVALS
Gas Test
Electric Final j
Waste Lines
Heater Final I
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover I
Sewer Connection
Encapsulation
Gas Piping
Gas Test
j
Appliances
1
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)