9907-074 (SFD)t
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of r:
i, "Chapter 9 (commencing with Section 7600) of Division 3'of the Business and
:'Professionals Code, and my License is in full force and effect:
License # Lic. Class Exp. Date
674074 V/13110'
ate r , ; Signature of Contract
OWNER-BUILDER�)ECLARATION
I hereby affirm under penalty of perjury that. I'am exempt from the Contractors
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 Yproject (Sec. 7044,. Business & :,Professionals
Code). r '
I 'am exempt under Section' B&P.C. for, this reason
Date Signature of Owner
C WORKER'S COMPENSATION DECLARATION "
I: hereby''affirm under penaltyyof,perjury "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
J performance of the work for which this,permit is issued:.
I Have and will maintain workerscompensation `insurance, as required by `
5e6ibn 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:
Canertr ,., Policy No: - 1T kTlf3 11
(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 nd-agree that if I' should become
subject to the workers' compensation ro�ions. of Section 3700 0 'the Labor
Code, I shall foAhwith comply with those provisions. ,rf" J
Date: 7/� `7f! Applicant '•) ; ..
//Warning Failureto secure. Workers Co pensation 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 ons his'
IF application.--- -r .
1, .Each person upon whose behalf this'application is made & eachperson•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'subjectpermit 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 ,upo9
the above mentioned prope for inspection purposes) J�'
Signature (0wner/Agent) �'� Da/
t(.,.M,r
�� BUILDING PERMIT PERMIT#
99 31-074
DATE r .* VALUATION 5220,8j2_.0(i) LOT �1 TRACT ��*9 t
12
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JOB SITE¢ -
ADDRESS "2,,./ V.0 .00NQU1%TALWR
APN t
649-2.1-0-006
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OWNER
CONTRACTOR/DESIGNER/ENGINEER
yPARKfS 01p1141STfiU11-110N
PO .BC}X ,716
79-295 RANCHO LA QUI TA DR.
LA QUiNTA - CA 922, 513
LA QUtNIA Cts 92253
-1941 CF3[:" ?96
USE OF PERMIT-
STAti�T,,E
9t D - WT 41 RAN B! PMRIWI ' DOEfi SIO T TN`CL UbE 19LOCX WALL
OR WY -OL, 7S°io i:+7.:AN C:HECK t EH REDUC"E`.0N FM1VtULVIPL Y,
138UjW1CF OR SAW. PLAN TYPE;
r,Li a'I' Ivf CQ1d>°3T JC"i'I0N' 2,605.00 3
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. P1:"NiAP.I.i�lg:�d��f,�
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. du ', Lb'9 i•UY.9'.:k.'+,M VAON 1164� C11 N
•gyp ��y �
&GiYyfpJ.fi.PJ�
w' a r P +' "' summAR a,
C0N81'.Ry1CT10N'FJ-X1.' L~7.1wliUt3-4121Ll()i! $t,f6:3AK)
P,IN n!� ak tc�t ::fX0..439 31 it . $21790
ME"MANWAI t; sa nt) -Iryl-a xos.�+
4.i 1."{ tCICfi1. i M t.4 f -tii3� <k2t�- $lki2.fi f
9'i.#JA913iIvIr 101-000-419000
i. "si tCJ dpi Ai( ': Tox l" 2? 1101-OW-?4s-i1t)M
1T�'�`t�! a �'R.$.7t."1"l3}'1:C.� :'.�:1�z � 2.2ati(k�-X43-3�Z ' . �i,3�f►.2i
ART UN PTJB(AC'.PLrACE,'S-'RESIC '101-00(3.425,5.000 V30113
x .Vi-MT.P L COr15MUK„`T.ZO ,AND PIAN CHl°: G K
LESS PR PA1..0 PE'E$
to -00, .
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.`r4f°.CM.,
Pfl"+',$L+ 11 91 VEE.8 DU3!:1`d'OVY
$6' 960.65
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RECEIPT
DATE
BY
DATE FINALED `
INSPECTOR
_
f.t;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 5'
Underground Ducts
Forms & Footings
Ducts
Slab Grade 641
Return Air
Steel
Combustion Air
Roof Deck i
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 1
Drywall - Int. Lath
Final
�(—
Final
BLOCKWALL APPROVALS
Sleet
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 ,- `
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 Z f
Appliances
Final
Final
Utility Notice (Gas) If. 6d
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)
COMMENTS:
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