0208-284 (CONR)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 th`e Business and
Professionals Code, and my License is in full force and effect.!
License # Lic. Class A i j I Exp. Date
Date Signature of Contractor.f:a�f'-
J I ., i r
OWNER -BUILDER DECLAR T O
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). .' 1
( ) I, as owner of the property, am exclusively contracting with/licensed
contractors to construct the project (Sec. 7044,1 Business & Professionals.
Code). ,�f {
O I am exe pt under Section B&P.C, for..this reason
Date r� 0 F, Signature of Owner r� 1 �`,
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) 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 ,ANIOC°AN CASUAL Policy No. WC2473$61 t
(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 sows torbecome subject to the
workers' compensation laws of CaliforniaJand agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, (�shali forthwith comply with t� e provisions.
Date: a1�X' 12 - i' Applicant
r s
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltiesanb 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 tirCyty,'and State laws relating to the building
construction, and hereby!+authorize representatives of this City to enter upon
the above-mentioned property for inspecti{on purposes.
Signature (Owner/Age ti-� 1 `+ Date
'1
BUILDINGPERMIT PERMT#
0206—
DATE VALUATION LOTS TRACT
24
JOB SITEADDRESS 8-�23f) I�trG,TN1.�.)9 WA
,t
APN
OWNER
CONTRACTOR / DESIGNER / EN INFER
a b:940 VON Xl!E AVE#.2(*
16944 ` OINYMI NT A^>`VE 0-2,00
a0h0l, C!A 92606
MV01R, ak 92606'
(949)4,42-6199 199 CraLff 6735
USE OF PERMIT
NOCELLAZbt—rous
SAIX.S' 0WIF3CZ CONVVIR;iION OF CASTIA PER MUP91002-350
V .A/Lli+Al ION 4,790.09 W
IWAMA111D VIOST 91 corigA„4-CUtoTIN, N
"S712'LIrV42
PLAN CHECK FT1110. 101.000.439-:318 $46.4
CO'HSTAtIc" t" ow m, -000,419-000 $72,00
1101
MECHANICAL RE i 101.000.421.000 110 50
I?:I.I�.%'I`I�CI�.I.I�I�s� ;T gt3l-0�2ti-tli9f;3 $:30,00
pummo I'm 101-000-419-000
.
000-7.4 0:! �. Sri
STR.t:'iWO 'WOIF'1014 FRY MSO 1000-24
CITY OF LA QUINTA
FINANCE DEPT.
$199.90
IMO W1 PAM 14M,
$0,00
WrALL MIS -Dtrrl NOW
RECEIPT
DATE [
BY y,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
0. K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final
BLOCKWALL APPROVALS
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
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underoround Conduit
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Notice