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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
i-)YI, 4152 13 OnW2N
Date / _6' LOOSignature of Contract6r Ae
OWNER -BUILDER. DECLARATION
I hereby affirm under. penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the propert�, 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).
( ) 1, as owner . of the property, am exclusively, contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
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 provid6d 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 is issued My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
IZOIL'All O.V, .01
(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 �ermit is issued,
I shall.not employ any person in I 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 p
Date: /=�2 400 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.
S,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subje6t 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.
PERMIT#
BUILDING PERMIT
DA71E JA10,10 2WAT10' $4124.336.30 ILOT TRACT
JOB SITE APN
ADDRESS W-67501',SERT WiLLOW STU, EIF '649-1634-626
OWNER CONTRACTOR / DESIGNER ENGINEER
�,VrVl I T TQ 1) VVTVV7' 10"M A I 11,1'yTjf;c� Mrr 0 1 VI'l t 1.3 17C I M17 Y41 'I A 1, C'"I r- 1 1 E'o
4,c ..4 -'%_14 I - . . ', W, I i. , �4 1 1, #. *��
1`0
PA;UiL -LAZA, SLIJ I f" 41UU 5 FARK PLA ZA, UYVE 400
IRVINE GA 9JO14 I it WIN E Cl� 9120H
t949)'15I -CA 1 (9) ('RV,1f S07-,
USE OF PERMIT
51,1-s - LOT46' VIAN 3 PERNRT DOES 1401f NOLUDE &,��-K 'WiUL Olt
VuOI_7!6� PLAN RW_)UU1` JQ.N APPL0J FOI� NIUL11KE
SUMP tfl,"I'AL.,
tCTYPATIQ SF
10
3�VtA0kYGAX,FU1(T 4^10 -OU 3F
1r, us�rlt".Ic TIONT
C01,13TRUC1110N FEL7
i0l-OW-418-000
$727,00
11) 1 -AM-4'Ak)__'A I R
A "MC. I L' � t 1.1� A L F VE.
M,
PLUMBING
10 t -000-419-ON
.Tt1Rr1iW(1 MOTRIN FRF RPS1111
10 1 _000-7 d 14`100
A � TN i?RtL11j Pi. ^CE;5 - MiD
70.1
QEVIJ_URVR 1(Vf.PAT_*'V FEE
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 above-mentioned property for in,§pection purposes. L
Signature (Owner/Agent) Date
S1 HVF(YFAI. 0014.i�*I'Rf 1(7710�4 ANI'l PI.AN Ct-112(lK
I 'Ps" N 4�
41 1J I r"11 f�,UD IVIEEIS
DATE
110TAI, VCRPAJT,V C04 DUE NOV
DATE FINALED JINSPECTOR
I 214113M.30 �t
%Z1 916 46
$312M.96
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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
'np/
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int Lath
—e�,Z_
Final
Final 1-5-2:5-2-4
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVA S
z
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
/,2 _;�—e.,
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 7::z 14
Utility Notice (Gas) C __11 / -/ t.
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) 2 Z I - c3a
COMMENTS: