0101-342 (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
47689 BS� F J1r°�C
Date f' r Fat Signature of 'Con tractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for thefollowing 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).
O I am exempt under SectionB&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 and 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.
(ol I have and will maintain workers' compensation insurance, as required by
Section 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. °
(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 forthvyith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage Is u, lawful and
shall subject an employer to criminal penalties and civil fines up toa$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..RR
for a permit subject to the .conditions and restrictions. set forth. on his1�'
application.
1. Each person upon whose behalf this application is, made & each pe sn kat
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 186 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),�_� r._:, :^--" Date's `"•_�
BUILDING PERMIT PERMT#
DATE VALUATION LOT 01.01-.342 TRACT
45 2149,71.1
JOB SITE
APN
ADDRESS 444 10 VLA COR0111% D_ Q
1-024
OWNER
CONTRACTOR/INFER
iENIMYAMR-10411.91r"'S W OPIYI'FI F, CORP.
f"`MMRY -*A2.IQK1,7bl r!' 0.'PMMrA, �;em
55-487 3011TIEUR3J°MUS
55.487 :300 1 t 3:`�t'-L,9
LA. QM' I -A CA. 99,233.
LAQW99'A CA 92253
(? n)W-5612 C`11a 51 '1
USE OF PERMIT
•• �.•�,p 7
SI=111= LOT 4 5 .Pi, IN IAP • PERMIT 001))'1140`x° 4Nl;l..UW1, $iLOM
WALI.rlPOOCAPA MAPPROACH DRIVKW A"Y.15W .AN t4HJXX ,Rr_-
YtMIJi" T11,C 14 FOR.1i6U1. TIPLE ISSUAI�Z P, OF SAME .4''l," TYPE
PORCHMATIO SF
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K&t:H.l+NICA1..ON. 101-000 421.00IO Mae
XL=T.PJC," FFIX 101-000-420-000
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VIAL COMM
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TOTAL FERMU1?'KESD '61
RECEIPT . `.
DATE+ t
t r
BN^
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings /� _
Slab Grade �!
Steel
Underground Ducts
Ducts
Return Air
Combustion Air
Roof Deck_$ �^ �►
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing _
22f ���
Compressor
Insulation
?js
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall _
Exterior Lath
Drywall - Int. Lath
4aV_ V4"U,
_
Final
BLOCKWALL AAPROVALS
Final
POOLS -SPAS
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 2 �� �
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans )[,� ���,L
O.K. for Finish Plaster
Sewer. Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas TestiQ'�
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
Detectors
Temp. Use of Power
Final
Utility Notice (Perm)