0301-082 (SFD)LENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
Napter.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
674074 B HIC,7/31 AY3
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:
( ) 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):
(;) l,. 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 Iunder 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 for which this permit is issued.
, :) `1: have:and will maintain workers' compensation insurance, as required by
Section 31.00 '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 ' T rU)q.T} Policy No. f]< &W38-','091,
(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"'thatif 1 should become
subject to the workers' compensation provisions of Section�3700 of the Labor
Code, I shall forthwith comply with those -provisions.
.-+Date' • .144 ." Applicant
Warning: Failure to Secure Workers' Compensation coverage is unlawful/and
shall subject an employer to criminal penalties and civil fines up to $100,0700, 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 Safetyiti
for permit' subject to the conditions and restrictions set forth on. his
application. " : `
1. Each person upon whose behalf this application is made & each personat
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, Jndemnify
&•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 uggn
the above-mentioned property for•ins�pectii6n�purp�oses.
"Signature-(Owner/Agent)"" + Date.k *43 ,a
BUILDING PERMIT PERMIT# i
DATE VALUATION LOTTRACT `
JOB SITE
ADDRESS 49-4W A C0PiQ:=AZAD0R
VIA
APN
649-210-W?
OWNER
CONTRACTOR / DESIGNER / EN INEER
POBOX 17 '816
79-295 W.,14MIQLAQ-MIMDR.
CA ? 2?W1
LA. QTMITA ITA CA 922W
(76o)771.49,11 •C BL0 30,96
USE OF PERMIT
P0014 SPS. OR DRIVEV4!AY APPRO ACH. 7513 DUCTION TO PLAX ONE=
M DUE: TO IALtiLTIP L WISSiUANC:, OF SAME, PL.�2d TYPE
r� � �'�'fJT'�� �O�>`F""Ei.���'it�Ai• �1��,f36 �'� -
,
POkCHIVIATIQ 580196 SF
GAR AQUWARPO.RT -694100 1',;F
WM4TED COST OktCOMMOMION
282,1MM
g;RgyA cm1wj41
..
00NOTttUCTION R.E.. 2CI:l-i1UCJA4I AG� i; 3t�:A4
,r
}ALAN CHECK FEE; 141-000-4. 9-316
1b4F.CRMICAL PER 1-01-000-421-000 3149:50
91 i'ilr3`f'1UCAL FEE
E'LUMBINQ ral l 1 fit-000.419-WOVJ5,q
STAGNO MOTION FEE =AP.73if3 101-.0i00-2' 1-1'J d! $23.21
101,000425a0y') $15,00
OVIE : PER WIACT rH3
ART W PUBIGIC P1r;AM e R199K sWKWO— 45.000 $2015.1
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u61614mi-i'dCrION AM PUAXRqq.??�MY,
$4,764.$0
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DAT N LED
INSPECTO
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INSPECTION RECORD
al 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
G q •-
Vents
'Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
01
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
i� 7
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 APPROVALS
Gas Test
Electric Final
Waste Lines H
23
Heater Final
Water Piping
Plumbing Top Out
_
6
Plumbing Final
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) __Z,; — ED
ELECTRICAL APPROVALS
.Temp. Power Pole
Underground Conduit
Rough Wiring 9_��✓
Low Voltage Wiring
Fbdures
_
Main Service
_
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) v b
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