0301-065 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that f 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
574(84 D 111C
Date j r 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).
(!)
Lam exempt under Section B&P.C. for this reason
Date 'Signature of Owner
WORKER'S COMPENSATION' DECLARATION
1 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 for which this permit is issued.
( ) -+have and will maintain workers' compensation insurance, as required by
Se 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:.
Cartier.;a,'rtt1A:jg1 Policy No.
(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 permitis issued,
I shall not employ any person in -any manner so as to become subject to the
workers' compensation ,laws` of California, and agree,th i if I Should become
subject to the workers' compensation provisions of'Section• 3700 of the Labor
Code, I stiall fort,
with those'orrovlsions.
Date:' rf , , r .r�' Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up,to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of'the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safety
for,,a permit subject to the conditions and restrictions set forth 'on his
application. ,
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers„ agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that l have read this application and state that the above information is
correct: f agree to comply with all City, and State laws relating to the building
construction, and hereby author a representatives of this City to .enter upon
the above-mentioned property for Inspection purposes. M
: 5lgnatiiPe (u'* F/Agenij :. _ r ' nate
BUILDING PERMIT PERMIT#
v
s
1 LOT 1 ACT
DATE VALUATIONxyTR
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR /DESIGNER /EN61NEEER
7) \/JEYEO.Mh(kS
1
VAAXCol'unRlwsoN
Z A (�,��I+3�"A CA 92253
L ,QUINTA CA 92253
IC()�d7Ta19��1 CK0 2996
USE OF PERMIT
MOLE RAtvMY D W-MILD40
NrO -1.0T W PLyAN 11±1.C: • PMRMIT WI LKS N0T 1NC:W= F.iWCX
•�'.!°+�..�a"ip3aF.tt..4�$���ar`6.+��.rim'!t'`'iiV".l�i��P':9t�.C!}`AL�1E, 7�aiG�la$+.�t'�3i%:',•!`:i�'�,.;_
RLODIIC` ION fa'CK 4'Vli LT,MLE iNS1,1AINCE OF SMkt PL -AN TYPE
CUSTOM L" 0,INSTRU :TION %3401100 Ifs
POtit HAIIATIO 580.06 0'
OMAGEMIAR'POR:T 03100,81?
t
' �i�sdiV:f1'k�a✓�7i1Y.1. T✓Y.� U:•1AA•C Ci��A�i9LY
e'.�?6e��%17e3�
PERM1 i RE >�'a�I�x�.r'�fARY
C��t`�1��4.1JC���`ra�a �"��� ���-��€a�•��uana �.t,a�0.4fl
PLAID CHEM PM, 104.-00ID i39-318 $261,23
MEWHAN M,
ML FF $14949
PLUM i7t7p�13J-000
vkomcl, ulna kaON FES RMSM 101-000-141-000
ti3PAD11 0:Ftp; T 1 C►tiit 3d0 (i �bS,Q�
1'.!►'i11�Y2�1.1t F.i+�1ytA;1 Ftr $��3t4�.EvrJ
Ag?.T ;tH Pt ,BL!C PIACHS - WME VO -000-443,000 $205:27
• ��.,17'.tif�.J.�IA�✓'4,.Vd9l7.l I.i la •.4'V1`A..111tlS+l✓yy??JR".f9t TEt;,0.RwL�'L�,iArIdln.
.$4,764.40
�+T. �y
. f lr IFERW :5 'S'11, NOW
RECEIPT
DATEt
BY
DATE FINALE
INSPECTOFY
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
— 3
Ducts
Slab Grade
/
Return Air
Steel
Combustion Air
Roof Deck
13
Exhaust Fans
_
O.K to Wrap
Framing
_
_11Q j
(9 -,75-:5
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
C"
Drywall - Int. Lath
Final
Final-� —a
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
3 --3 5
Heater Final
Water Piping
Plumbing Top Out
---�
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection
_
/ -
Encapsulation
Gas Piping
Gas Test]=3�
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit _
Rough Wiring — `Tj
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) D -�
COMMENTS: