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LICENSED CONTRACTOR DECLARATION
I1hereby 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 #q f Laic. Class Exp. Date
Date � f `" l ) Signature of Contractor'' _� -�''� "'"`�
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).
( ) 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 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).
(K), I certify that in the performance of the work for which this permit is issued,
Ifshall 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,1f Section 3700 of the Labor
/Code•• I shall fort . with comply with those provisions. } ,,
V Date:; %/(,- "' Applicant
Warning: Failure to secure WorkerCompensation 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 r representatives of this City to enter upon
the above-mentioned.pPOperty'for inspection purposes.
/Signature (Owner/Agent)4��/"" Date
BUILDINGPERMIT PERMIT( CoNTROL#.
DATE VALUATION $47,000.00. LOT TRACT. 6947
,/,,"/,,,,,
JOB SITE'
ADDRESS SZ -8b) F11SCINH.C)1WER DRIVE
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JEV•,!.E t'.w 111*3.ps '
WIESS IAN ENTE PMSES
52820 EISENHOWER OR
PO BOX e58, LA. QVIP+3'IA 92253
LA QUiWA. Citi IM253
PALM. SI-'YUNGS CA. 92264
(760)5 A5 6557 CRL4
USE OF PERMIT
SULDING
a 1111 DA&4JW,E 10NUR - rc,WHIJ3 CAicil. Ej NEWMI U S—t�S OVER GARAG
ANL)'W OF HOUSE,
r
VALUATION 47.000.00 LS
ESTIMATED, COST Or, ODNSTRUCTIIIGN-�.,
47,00o.09
SUNTMARV
PLAN CRECi l E', l f)'! -000-430-3IIi
CfIN 1"tbtis; l'1(O3�t I�> I01, -f 0�-�3 R-4?QO 130 5, IN)
ji13i:�.�i•1A:NICe1[.�,� 1GI�QOi1-4aI-� - �47.Kl3
ELPM SQA' l FEL, 161460-420-000
101-000-241-000
I"9t
LL
AND PLANCHECK
HECK
' L sS PRE-PY'dD FEIEs
10.01
'i'OTNL 0il;.r>~tM rf FEES 011:ENOW
S79t.95
/
��A
RECEIPT
DATE
BYy
D E INALED
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 71S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath /
'
Final 0�
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
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)
COMMENTS:
,
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CITY OF LA QUINTA
SUB -LIST
CONTRACTOR k4E- "`'"i S ADDRESS 55S •` ,C�.•.� C i?S
OWNER -3,? -kis JOB ADDRESSSzfs �►��.�
This form shall be posted on the job with the Building Inspection Card at all times in a rnncnicuoua place.
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
are on this list are the same persons performing the work. Any changes to this list must be approved the
City of La Quinta Department of Building & Safety Cpl to work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.
TRADE
SUB -CONTRACTOR'S"
NAME
TYPE OF
LICENSE
STATE..
CONTRACTOR'S
LICENSE
NUMBER
WORKER'S .
COMP..NAME/
NUMBER ON FILE
CITY
BUSINESS
LICENSE
NUMBER/
EXP. DATE
GRADE7.
EXCAVATE-
\\`
A/C -12
PIPELINES
IQ/ 14011C-34
CONCRETE/
FOUNDATIONS
I I _
�i�J��y� _6T.
�� 3i 49
I Qc>�ZZ��
rJ03$ 2 t 4
ASPHALT.
A
FRAMING
�E=jSTar'P cprc,
B
154tO6-
STEEL/
STRUCTURAL.
-�
C-51
MASONRY"
KI/
C-29
PLUMBING
�ijC-IGI, l I WMPj ,
C-36
1P
Cj D c3 (a
T'L
ioi98 i
l 22199
Q
LATHING.
C7 L,AX 4F RAtgw
C-26CD7`(�
3 5
I 3 4
DRYWALL
C-9
PLASTERING
C-36
HVAC
f!7ro A( Q_
C-20
6 9 a &O
ELECTRICALj
(General)
44 l'L, EAG
C-10
7 1-7 % % %
ROOFING
C-39
SHEET METAL.
C-43
FLOORING
C-15
GLASS[ ''
GLAZING
ry/p-
C-17
INSULATION
J tr`
C-22
3
5 l 7 Zy
1(Q 3 0
SEWAGE DISP
C-42
PAINTING/ _i;
DECORATING:
1/ e , ,
C-33
TILE :.
/`\ �-
C-54
CABINETS/
INSTALLATION>.
C-6
FENCING
C-13
LANDSCAPING-
C-27
POOLS
C-53
OTHER