9809-256 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of •.
Chapter 9 (commencing with Sectiori•7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect., ..
License # Lic..Class Exp. Date
a
67,:1074
!✓
ate' : Z'� 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 thea 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
!'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
XSion 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.
cS``i r`1,'t`t 1! N I '046 -IS UIVTTC>007335
(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
worke ;s"compensation' laws of California, and agree that if -I should become
sub'ect to the workers' compensation~provislons of Section 3700'of the Labor
Cde.1 shall forthwith comply with; those,,provlsio e. ' 4
,pate:-. Applicant - �('..''�
_ V
Warning:. Failure to secure WorkersCompensation 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
fora 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 I have read this application and state that the above information is
correct. l*agree to comply with all City, and State laws relating to the building
construction, and he authorize representatives of this City to enter upon
the/�Zbove mentioned property for`nspection purposes
Signature (Owner/Agent)—F 1Da,te
PERMIT# °°TN. TRk°
`"BUILDINGPERMIT
DATE VALUATION e;6qn,852.00 LOT.TRACT
�- _ _
0/ /1's,
JOB SIT f. T`5 4!N# � !•q Z Df i�:.
ADDRESS
.1Q1-042
.-_
�APN,649,.'
OWNER '
CONTRACTOR / DESIGNER / ENGINEER
P.O.. BOX.117,10
m.295 RANCHO LA Q11I:tNTA D11L. '
tit'1`A 21
A '92153
QUIWA,�C
USE OF PERMIT
SINGLE i AMLY DAPELL1NG
SFD, PLANUI, LOr St; 'PERAOT DOES NOT INCi;<tME'SLOC.k WALL 6R
POtDLYLa<eN Ck1J C.tb. r'E REDUCED 75p,�A.F'Oft 44ULT1T'LE ,ISSUANCE OF
S ffl,4E PLAN INPE,
L"UST CW CONST F UCTIOW 3.635.00 Sc
PORCH/P.ATYA FEi7.ii0 s
,�
GA4ZAfif�Jl ALZP ? 2: _ 614.00 "4
ESTIAWY ED COST OF CGINI&It'd UC IO d
PI;;.Rli` T VE_P, SUM1bYF RY
CONSTRUCTION I'EI-11 10I -M-418-000 51.,003.00
!';I PN CHECK y�. - `a�.l +3(?l}a�-3.lQ - gZ:?7.!at)
M Cl1AMAti7a 101-i1�-1`21�OE1�1 5�05.6Ei'
LT:r CAI.' fra .101,000 20 000 �9h2A.)i
PL (.i1blAi:ING FEE 101-000.419-000 $179.25
�STRf)'ATr IIS Trf,t.F 1�;FSIj7 ift1-60n 4t Etf)>? 2ry�3g:
4
W1a,ASTR[7o''t`LTR.F.M, I JT"00,I43�342
Af' r .IN PLIBLiC PLACES - RESEC 701-OOL 255,60(1
.l
.QN T JCTI.ON ! PLAN, CHECK
E� -' t "iAi C: '
TMAL PL MIT Pf"t
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`
RECEIPT �j j r
DAT/E
BY °
DATE FINALED
INSPECTOR
INSPECTIOU RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs`2%
�
(
�L�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
9 ,Z_
��
Return Air
_
Steel
Combustion Air
Roof Deck
O.K. to Wrap
Exhaust Fans_
F.A.U.
g
Framing
_
G-
_
Compressor
_7�7Z
Insulation-
o
�vl
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Final
�7
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
_
l -C�t
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
��l ll
-/_
�LG
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�2 1;2-
�(�C
Appliances
Final
COMMENTS:
Final
U
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
i
Final
Utility Notice (Perm)