0301-088 (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
CY 34YJ'r"4 ?3 Mt;�,r- ?��� 110
r
Date' �'w 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).
( ) I, as owner;of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & . Professionals
Code).
( ) ,1 am exempt under Section B&P.C. for this reason
Date Signature of'Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm .under penalty of perjury one of the following declarations:
()
1 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.
S c() I have and will maintain workers' compensation insurance, as required by
tion 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 'STATE MIND 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,agree0that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code,' I shallforthwith comply with those provisions.
Date: • �p ✓ '° 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.
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, indemnity n,
& hold,harmless the City of La Quinti, 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 prope rty-for-inspeetion%purposes.
BUILDING PERMIT PERMIT#
'
DATE VALUATION nb95,4(*&) LOT 33 TRACT 29283JOB
SITE
ADDRESS 49-544 VDi CONQUWAD0,1?
�APN
T
OWNER
CONTRACTOR/
CONT�Rt'AyCwT�OR//CDE�S!IGNiE�tRIE�NNN,�Ee�E7Rf�y,1
1���gy.�T1 �l��p�� «��y� �y �q�7
TD ,FJ•L'��ci.MIR DL V d.'�+a�vA'.[Md�..O
kvK"J9Lf-l' 8 LiOKV 4'7.��bg UC1110.JS`f
LA QUA%tea CA 92253
U, QUL �U C:.A. 92253
(160)771.1941 MLP 251,46
USE OF PERMIT
WHOLT-7 RAW -Ly DIRM ANG
`.
P001, 9M OR Del EWAYATIPROAC.H. 75%RFr.D CT10N TO 4 C II! PK
MIM, 'FKSMU TIPLE ISSUANCE QIP SAME PLAN TYPE
C'U&STOM CONS"eRUCTIOW WOO P
POF CHIPa AT10 446.00 SF
GARAMUCARPORT 63610 SP
iApp(����j .SRV
P�r•^y�y.��%g45 41 �``y' �+yy`{f #rypSpp:
���``t'`` /p p p p �p q �+ q�hY� a
4�7SV6,7di40+���rEt4+.i9 S'EE .01-000--418-00 • 111131.1.30
PS.,ttN CHECK; FEE 1611 000.43MU SMAZ
mwmWaA L nem 101-000-421-000 $121,00
-
FI,WNZ1C.AL Ki~ 1,01-000420-000
Lii il�INt FZ� 101.000.419-000 $229,00
.0,140 MUTION FEE!, RESID 1.01-0.00 241-1100 $29.91
a'11 &DINO FEE' 101-000-423»000 gf .pt►
ART IN PUBLIC PLACES - N�01.t 270-000,445-000 SZ38,$2
jc. .xr, •?• v1
' suB-T(YrAL�'L9Kr?1'Atk �`) A.HDPI.t�i� GRECS
,�d�i. v�
'' ' ?�u'c1:39 'i2 �P�lri IYla;�iS
$0.00
JNIv q 1UU3
ff;���
i.my OF LA 0zfEr, A____J
,
FINANC 7
;RECEIPT f
DATE -,.iBY
DATE FINALED
INSPECTOR
ilk -
Low
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p- Z
Ducts
Slab Grade
3
Return Air
Steel
— v —S
Combustion Air
Roof Deck
_ J 7_3
Exhaust Fans
O.K. to Wrap
O.K. for Finish Plaster
F.A.U.
Framing
7— -S
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
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
Heater Final
Water Piping _
/
Plumbing Final
Plumbing Top Out `� -
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
El
Encapsulation
Gas Piping
Gas Test /a /_ 5 —
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit !1
Voltage Wiring -
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) / -
COMMENTS: