0112-073 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions- of
Chapter 9 (commencingwith 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
478689 � � 3/ 1102
.Data $ � ' t2 Signature of Contractq�. f �,
r . -
OWNER -BUILDER DECLARATION
1 -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). ,
() I 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:
( ) 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
Section 3700 of the tabor Code, for, the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no.'are:
Carrier Policy No.
GOLDEN RA54.01181 3v'W $4701401
(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 foi 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 'Jh se provisions.
' 1',l
Date: I Applicant � ��L - --�"": �.-.
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.
5'.
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. T
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 cf 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 iur'poses J` 's•t:
Signature (Owner/Agent)"""'"---'4�
x
3I:�• t r. ,
BUILDING PERMIT PERM T#
DATE VALUATION LOT 1. 12 TRACT
$14,6" 23971.1
JOB SITE
APN
ADDRESS 014-Nk 'VIA COIZOVADO
6(M-2.1 1 -0.2 7
OWNER
CONTRACTOR/DESIGNER/EN INEER
ir-047TIRYA.15+.tMCAW Dfs..VP OPMEN , CO]
U), Ott 4TUTf Y .A ICdIN.DE V i.OMP141', CON
�}.f'�S.�A
e ,l eY�, ?:
^y78e�"'5'2'0`�yV�:�p�2h.
�Y Ay
* p�u'-^'J• �, yy�p, �.i7
92
(760)W. 5612 MA :G4V
�•<.
USE OF PERMIT
(9ft {) y E yy qy 'gyp.
'.I.,CIT 4t PLAN IA. PERMIT DOE$ NOT i11fCa. UDE, B1R3t X W.Ai,I % ;
PN004 SPA, Oil DRIV9WAY APPi2C3ACIEL
TRACT T C'.'Of1N'I'1.'.•I.1C710N 2,461.09 SP
POPIC.WPATIO 76.00 V
(At'al;At39?.i17A'idI'ORT 6X00 8F
ESMWA` M) 60Sd' CW C<3NS'�i.`�L""U011
A46'7XM
PMMIT"TOE 94T_fN i Ry
CONSTRUCTION FEM 101 -000-418-000 S904100
PLAN CHWX PUB $5a9. -M
1iKd(3(`},>0�=•�d5•2r2y-�'I[t�y�°3gi MOM
EE 101
y��Ri�/Ikl�.]�.ly�IC�y1.A�..�I.
Ju1f1 V ICAL ."Sy=!
N,UMBlAO9I lCZx^ ®>Rl �Ctt $i6R,5Q
k1R AD1H() i• ,t ?. 101 •i06. 0-42N.' 0 .s`4' $.4i+.011'
rumf al'.Y.R I'"+9rnACT F•1'E �a,yts7.a7Q
tj._1 aAL. C°e.),1qaWiy%"�`•�>:C31+# AND P AW CrIMOCK
$3,79S. -Zi
T,M;9`,� PS,:1v PAM M14)
so"01
' ''19L�.� >r3C Tz'3 A T�Lr.9 � Plow
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
_/^�—
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Slab Grade
_ -
/d _15�
Ducts
Return Air
_
Steelf�
_
f� �Z
Combustion Air
Roof Deck ,�� ,' /=�
Exhaust Fans
_
O.K. to Wrap=
'a
F.A.U.
_
Framing
:5 - / Z
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_ _
Fans & Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
S - Z �_'S
Final
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
-//_ Z
Plumbing Final
Plumbing Top Out
3 _// _ Z
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
y -��_�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
_
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final - -y
Utility Notice (Perm)