0308-247 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and .
04 W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
LO
LU
r- 72010.2 � B Ric 9130/04
Z r� Date, -1 �' Signature of Contractor 'L�f r�%/`✓
J Uc OWNER -BUILDER DECLARATION
rl-
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: �.
Z_ ( ) 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). _
M O I am exempt under Section B&P.C.�for this reason .
LO _
N Date Signature of Owner
0
N
Q WORKER'S COMPENSATION DECLARCL
ATION
CQ Cc I hereby affirm under,penalty of, perjury one o, the following declarations:
F_ Q O 1 have and will rmaintairi,a certificate of consent self -insure for workers'
X W compensation, as $rovided for -by Section 3700 of`the Labor Code, -for the
m J Q _performance of the work for which this permit is issued.
Q U (,) I have and will maintain workers' compensation insurance, as required°by
o V, Q Section 3700 of the` Labor Code, for the performance of the work for which this
d LO H permit•is issued:. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
CO OW) tREP0131,1C INSt? I> 11Vt"10@34;�9E+I1
J (This. section need not be completed if the permit valuation is for $100.00 or less)..
? O 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
y ` workers' compensation laws of California; and agree that if I should become
Subject to the workers' compensation provisions of Section 3700 of the Labor
3 Code, I shall forthwith comply with those provisions.
r Date: ✓.,/,t IC - A 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. I '
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.
[,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)X/fy'lriIel-�/17� / Date..��'� 13
BUILDING. PERMIT . PERMIT#
DATE VALUATION LOT Ce"M247 TRACT
S157,175,30 7 3C152Ta1
JOB SITE
ADDRESS 4. VEA CiA71ALTRA
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
LF" AR ROWe 0 OF C: A R'fP
Mi'AiAT0. HOMM Or, CA-1,YJR141A
78.401 C: ]RJORWAY 31 T
78.401 O 1-WIRWAY 111
1 QiJ11 TA C.0, 92253
LA QWrA Qk 92'253
('360)771-0131 CBL0 3434
USE OF PERMIT
SA401ZFANLY DN LMG
.;FD . 19T 7, PteQiil Ski ' PI:7:(WIT 17t33L�.., idC2T 114C&,VDIT k1LOC.K WAL.I.S,
POOL, O)'.A.OR latRNEWAY AP-P:ROAC'.H- 74 % UMDUCTIOPD O PT.,Ax 08ECIC - '
SEE UCFE TO MUL,TIk'LX ISSUANCE? OF SAME PLAIN `1'YPP, ;
'fl -ACT CO)OSTI1;t7C IO7N 2;1;# 3,00 3F
PORC11>tPATIO 236.00 SF
CARGO dC.ARPORT . 416.00 SF
: SIM" 3 G( sl' OF COMI.
157.175.10
10
CONSTRIXT16N FEZ 101'-000-4,18-000 X42.':0
P si:t+I CHIECK FI?k $(1i-t3t1Ci-4 s�-318 $F`ta. i
NIE(1'd MICAA FF% 101-0004U-000 1.3130 $69100
&LIPC=t'I,ICAL'M?LI $131.93
PIX M.91-NO'M 101-000-439-00.0 0.0 $16"1.25
S5'P4C5ND MOTION TION PEE - HSYD 101 -,000 -?,fit) X000
ORA)NY3C3 P1,11. n11. 101.000-42:3.000 $16.00
T:r)' EWPF R. ITt PACT:iUR 2,dlt3.Di1
t:Fl -TOTAL CON I iIXTC'1;tOYl AMMAN ~'I; AN CIM -"C
X3,81 �!•. �(i
ISSS FREIPAM RUM
So. 00
TMAL 1< _YRWX 1t!'M DUE 141'C'1W
tLEC5
2003 P
RECEIP
Cla"1f
DA
l; py`�.GY01'S�'I•Ei�_:.�
Y
DATE FINALED
INSPECTOR
'
,%'��
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE --
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
Slab Grade
Steel
/ _ _
_
fi
Ducts
Return Air
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
.40
Compressor
Insulation
_ _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior LathY
W16
Drywall - IM. 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
Gas Piping
PLUMBING fif WVAL%
Gas Test
Electric Final
Waste Lines
L
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)