0308-246 (SFD)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
-Iis,* o2 B H[1711 9Y30104.
Date' Signature of 'Contractor✓�� -
OWNER -BUILDER DECLARATION c_
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). ' a
(-)• I am exempt under:Section B&RC. for this reason
Date ; '' Signature of Owner i
WORKER'S COMPENSATION DECLARATION. '
I hereby affirm, under, penalty of perjury one of. the following ,declarations:
O 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 forwhich this permit is issued.
(7). I have and will maintain workers' compensation insurance, as required by
Section MOO the Labor Code, for the performance of the worklor which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Cairier Cyd, REPUBL-1c. Policy No.
(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
subject to the workers' compensation provisions of Section 3700'6f the Labor
Code, I shall forthwith comply with,those provisions.
Date: �..% l . ii✓�i Applicant��/,'�/1
r
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 thecost 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 restrictiohiyset 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
,-'Signature (Owner/Agent).��� �? Date
._e- _._ _.
PERMIT #
BUILDING PERMITS
tea•
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 44-875, WA CATALIN .��--:�.�,�
APN
)II
OWNERCONTRACTOR
/ DESIGNER / EN (NEER
:t, taz, ox,• G IsUiOlUn
p, � , za .� Ur' C 1
78 11. C'.13i� IV"?l�Y ] 1.3
73-401 C BICTHW�AY 11 a
CA 92253
LA. QUWA CA 922S3
�
(7601777.0131 C`BW 3434
USE OF PERMIT
ITOIX r•� LY IMMILWO
Sirt7.1W 6, PLM IC. PERMIT DOE—SNOT INCLUDE HLOC9, WP.LLS, � 1
P0014 SPS QR`CRIV F -WAY APPROACH.
TRACT CONSTRUCTION ;s,3uvc S1%
PORCHIPATIO A88.00 SF
l
Ck1�1tAt1><.fc:,��:1c�R� 4,62,tt0 Sty �i "•
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.I) cos—I' w idom C."1 m
1(D yQiw2. 43
COMs UCTIOr FEE 101.000 -4 -IS -000 $3001so
PIAN C
1Vt'RC��AI;(G�`t1. f'i�L 1 O a-t3E3t�x�2 t mi}Liq $`9'9.tiQ
Ei..WW I AtICAL ME 102 -000-420.400 $126.22
PIXIMi1F O F E1? 101.000-419`,000 g16G,i1i1
eTRUNCI WNW FEE a REBID 101-000:•24.1-000
GRADING kME l01-t1CtQ��36U�tJ �iS,EI�'
OA7AND PLAN CHECK
RD
TO Y'. ,1'K�..�r? £+;S DIVE NOW
CiFI OF C./
Dtie
Eil�iAft9CE DEPT.oil
RECEIPT
A
DATE
BY
DAT FI n IN PECT
_
.f• !moi •r1
�
/v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs / _ _ _
Underground Ducts
Forms & Footings_ _ _
Slab Grade ��
Ducts
Return Air
_ _
Steel
Combustion Air
Roof Deck _ _ 4 i _
O.K
Exhaust Fans
to WrapI_'
F.A.U.
Framing ('00,
Compressor
Insulation 3 ,(�
Vents
} /„
Fireplace P.L. (((/// (
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
e
Waste Lines r
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:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring ..�Q
Low Voltage Wiring
Fixtures
✓ _
Main Service
Sub Panels /
Exterior Receptacles
G.F.I..01
Smoke Detectors
Temp. Use of Power
Final 00,
Utility Notice (Perm)