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LICENSED CONTRACTOR DECLARATION
.;I tte; by,affirm under penalty of perjurythat 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 Ii Lic. Class Exp. Date
Date 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:
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 -e a pt ufid /r,,�Section B&P.C�_.1014s�e n �,
Date i�� y Otl
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).
(',Fcertify 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 to1he workers' compensationprovisions obSection 3700 of the Labor
i,Code, I, sf} I f6 A&comply with t ose ov sions:9
,l 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 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 authorize4 re - re��4htatives of this City to enter up • n
the above -men' property fo.�lns e tion purposes.
ISi nature (Owner/Aggent)31 Date" /
BUILDING PERMIT PERM' ab��f� °°NTR°`�
y 2979
DATE i Hr1+s VALUATION LOT TRACT
JOB SIT E 78410 C.I��r�i�,.�sSTADO,STE
ADDRE
ADDRESS
APN
•769-10110141
OWNER
CONTRACTOR / DESIGNER / ENGINEER
02171.11.Lr1t 1 O'CAN'
OWNEtt BLIIl. DER ;
P.0.BOX- 1.397
LA QIJ1N1'A C.A. —153
(619)771-8400
C BLI!
USE OF PERMIT
If?NAW M'1k0V'i:&!J.Nt'
SEN'S'ES 1002,103 ANIS SSI
(:'Otd'fRAC'P AM.0Ut41' 600.00 .I
F811iAIV,0 C0ST CirCON S'1 RUCTION
f13f3.Of�
014'ST 2iJC,°1 SON F 101-000-418-000 $17,00
.lkT.la... S'ItWAL Fri- 101,006.420-1300 83.00
SUB -1`0 C0N91'KUC fIGN WND PLAN 041XIK
$11,01
LESS P t-EAI.0 FEE
$0.00
` 'VIT'9L PFRM.ff FERC �DUE NOW
$31.05
N�
RECEIPT
DATE
jBY
DATE FI ALED
INSPECTOR
f t
t
INSPECT'ION RECORD
OPERATION
DATE--,,
I 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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
\ BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
_Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
t
OPERATION DATE INSPECTOR'
MECHANICAL APPROVALS
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plba. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Encapsulation
Final
COMMENTS:
/�tJOTH E R T Z
M EXT TUDOR UTILITY
CL05ET
I
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(DTELE P V+CQE
ELECTRIC 02)
TENANT Z.M FRONS M EINTS
LA 0 UL A VILLAGE NTIQI.(,ES +C C3)NG FANS W�L.iGHTS
Su. ►TES I 02,
BOGAW VILLAS
7g- I zo CALLS ES'rAoo
SCALE: /e" : I'•0"
LA OWNTA, CA
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CQiJN">:Y YIRS C}11EF
RIVERSIDE COUNTY
FM D E.PART 1�L N'T
2119 wF1ST SAN JACIS"M ?,VENUE P'MIS, CALIFORNIA 92M
(714) 667.3188
Toa, fes , , , W l ann �, na Departmvn t
r~.. 5urve9yor' n Office
X &uil01np And 6618ty
The Riversido County Fire Dvpartmwnt hereby releaoos;i tho projwitt
140tad talowl
Lop Number i i �i 'Ca 2
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Y1 you should havo any qupati*m% rggard4MQ thia Matter, plaas3o do
not houitato to contact the F:,ry Department Planning $action
$toff.
RAYMOND Ho RE019
Chief Fire Dopartmamt Planner
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Cc t f i l ca FIRZ FRS'Gc' loN DIVISION
PLANNING SECTION
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