0101-339 (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
F
Date n �, !r Signature of Contractor ell.
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. 704.4, Business & Professionals Code).
( ) I, 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
Cato __ 8ignaturo of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of 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
performance of the work for which this permit is issued.
( ), I have and will maintain workers' compensation insurance, as required by
S4 ion 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 Policy No.
o30D:rY;A�°'FI 'l�,t'at�,�? iJ�I;` :�d �+'►I/j�l
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: i A' ' •" to Applicant—
Warning:
pplicant Warning: Failure to secure Workers Compensation coverage Isunlawful 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 kF In -§action 3706
of the Labor Code, interest and attorney's fees.
g.
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 perso gat
whose request and for whose benefit work is performed under or pursua �o. .
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 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 property for inspection purposes.
Signature (Owner/Agent) _ t �'1.p1._d. Date
-BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0101-3',§g TRACT
JOB SITE
APN
ADDRESS
44-4320 'SIA. 100R.C3NA
C434-211-021
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.4.5.487
?5.497 SCrUTBERN H91.45
LAQIM74A. CA .922:53
1AQ17INT'A CA 92253
(3C+ �5fa9�"�fil2 MIP 540
USE OF PERMIT
r
SYD . LDT 42 PLAN' I.� RP '. ,PRRMIT DOES "t QT 1-WU .s„ DE Bi,QC.K'
WAIA4100I. SPA, OR APPRO A N DRI 1rZWAY.` 5% PLAN CHI.CX FFM
l:3VI UC"TION FOR MtJlM:PIX ISSU DICE OP :;AME PI," 'rYPE
T RACTI'' C:ONSTF UCTTOPB 2,d�iI,E3p OF
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pI
47f4RA.'11'7+'.�7M1n5e.A1.�tAT (WD 62132940
PIMOM MR fiT MMARY
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PlIU Si INO FEE 1011-000-419-000
3rF2.ONG MOOT 4—nva., re s= 101 .,000-241 -000 fl�.att
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$0100
TOTAL N9.6drVIREENDTIE NOW
S3,314m
RECEIPT
DATE''' }
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _ _ _
Forms & Footings
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
�t,�y�/�y
faF
Exhaust Fans
O.K. to Wrap
Framing
��(
F.A.U.
Compressor
Insulation
_ f� _
Vents
Fireplace P.L.
_
Grills .
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior lath
Drywall -Int. Lath
/
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
21c�-�i<
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Z fj�
(�,1�
Pool Cover
Sewer Connection
(��
Encapsulation
Gas Piping
Gas Test
,
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
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)