0301-069 (SFD).,LICENSED �CONTRACTOR DECLARATION
J her;by affirm hder penalty of, perjury that I am licensed under provisions of
ChaI3teiV9' (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
07
6744 B BIC 7/31103'
Date'74% 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:
( ),, 1, 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, 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 under penaltyofperjury 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
p . erformance Of the work for which this permit is issued.
l.have and will maintain workers' compensation insurance, as required by
&Ction 3700 of the Lab6r Code, for the performance of the work1for which this
permit is issued. My workers' compensation insurance carrier *& policy no. are:.
Carrier _1RUATE PAW 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,
l,shall not employ any pe�sonjr�any,manner so as to 1�6cogj's6bject to the
workers' compensation laws of California, - and agree ,thatIf—I si�o ; uld become
subject to the workers' compensation provisions of. Section 3700,Pf the Labor
Code, I shall forthwith comply with,tC6��eprovisions.
.Date: Applicant
X
Warning: Failure to secure Workers' Compensation coverage is unlawful a)n,d
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 whosebehalf 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 abovd-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-inspectii5npurposes.
Sig naitu' re`(Own6r/Agent' Dat
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
83
14 29283
JOB SITE
ADDRESS 49-439- V14 COATQMnIAT)OR
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TI)DEBMT D n3T-.L0.PK W-1
MVIRS CORTMUCTION
POW -K. 1716..
79 � 2,95RA W, C1103'A Q1)XrA DR,
LAQUWA CA, 92M
I -A QM m CA 92252
(,760r,11-1941 MW 2W, 6
USE OF PERMIT
SMILE FAMjLy-DWq' ING
NFr) - Wr 14 IRL&N.M13 P&MIDT 0=4140'r ENCLUDE OLD= WA1,L%
w
P004 24M Ok DRPIR-WAY APPROACH, 75% wxcwc now ,0!)1dW cuvwk
'IDUIX TO MULTIPLE ISS"IJAWE CYFSAM P1 - TV, B
CI)STOM CONSTRUCTION- 44443. DID 8F
PORMUPATIO 02,00 SF
MMKIEDCOM'OF CORSWUMON
35111389.30
M"Any
C043TRU017104PPM oi -om4 i s-wo. $1,121,50
STROW0,MCYTHYNFZZ-USJ.D 101.000-241.000 $3114
ORAWRO RN,
DEM01"I 1PAZ IMPACT PZE
ART 1H 1,',UBW0 PLA,(. -,K8 "RIXK 2`10-000-40-000
;9'0Wr4Y,fAL CONSTRUCA0.9ANDPLANT (5,MCK
$3,25103
LE3,9 ,I 1p -x. -PIW MIS
$0.00
Tam 1:100M. IT= DUE 11f ow
RECEIPT
DATE
BY
DATE
INSPECTO,
INSPECTION RECORD
" OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings3
— 3
Ducts
Slab Grade
— Z. 3
Return Air c J
Steel
-3
Combustion Air
Roof Deck
3
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
�j=LO
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall.- Int. Lath
� �
-
Final p p
Final
POOLS -SPAS
BLOCKWALL
AP ROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPP VA
Gas Test
Electric Final
Heater Final
Waste Lines j —3
Water Piping
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
z
O.K. for Finish Plaster
Sewer Lateral
Pool Cover.
Sewer Connection
_—
Encapsulation
Gas Piping
Gas Test
-
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL AP OVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles 41
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)