9907-070 (SFD)LICENSED CONTRACTOR DECLARATION
1, hereby affirm under penalty of perjury that t 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
674074
Vpa e ! 7/�' Signature of Coni or
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,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,COMPENSATIONf 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 fo6vhich this permit is issued.
( 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 anyperson in any manner so'as to b ome subject to the
workers' compensation laws of California, and agree that if I ould become
Subject to the workers' Compensation provisions of Section 370 of the Labor
Code, orth ith comply with,those provisions.
hdU f
e: // ✓ 1�, APPllcant
r
WVarning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to. $100,1)00, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest ano.attorney's fees."
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to 'the .conditions and • restrictions set forth •on -his
application. -
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall; indemnify
& hold harmless the City of La Quihta,,its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced Within'180 days from date of issuance of such.
permit, or cessation of work for 180 days will subject permit to cancellation..
I certify that I have read this application and state that the,above information is
correct. I agree to comply with all,5piy,_and State laws relating to the building
construction, and hereby authorize represe tatives of this City to enter upon
the above-mentioned roperty for inspection urposes. '
gig ature (Owner/A�ent). -"��(� Date/"�
` BUILDING PERMIT PERMIT
• 0 )7-07$b
DATE �} d - VALUATION s .t rm.o LOT 3 � TRACT 28912,
JOB SITE ADDRESS X9-91.5 V,$,e�'Aii�.�.�9,IN.f1!
APN ' b����$1�5.•4�$i� �
OWNER, •4`
CONTRACTOR / DESIGNER / ENGINEER j
�y(••••�� ((�� 11 p , _
'i D 3./ES :a1 r �..+ �'�°�i.�.j xopi`i;ia , .-
ry 7�` (ten � � ��+v�*/�ryp
STARKS 'L+L/*4a'h�.�`� ii L.. i. YON _
0. Vilid r
'79-295 JLANC O I A Q1INFIA D.R.
L.A. QUINCA CA 92233
LA QUINP.A dA 92253
y -.
(7 017iJ.=1441 CBL# 29 i
USE OF PERMIT t
SrNi LE FAM1LTIAVE(.1.iN
F K LOT Y7 .PLAN ],2 - PEEMUT D09S NOT IZ14TOL.UDE BLOCK '1NALL
019 W OL. , :15°/0 PLAN O?41 K FiR',t RLIDi.iMMON:POR M L.ft'Me—
ISSUANC OR. SAIV.L PLAN TX.PFa .
�.�S 0114 CONSTIrIA-1ZION Z923.00 (?
F'piZN/kd f'Ia 3 ' 235.00 3.F
-
GMIAGWCARPORT 470M SF
rn C(I, Or, C0.JNd.Y..i UI KION
- l24011d.71 30
LY-S}MaiY,,.3m8fC
CCiNS'.MUCrIOIV:FIM 101-000-418-000 �1•t3'3.t1t1
AV.0 9;MNIC.A L ! 01-000-421-000' UA56
M1 000420-060 W914
PLUMBING, FEE 1017000 -4119 -NO
`8170,NG 11ftOTIQNt -17. tiI19 191 2,414W $24,01
GRI -A IN'01 Ftp $20
it+tr`i aaS f'I Lii; CUIt .1-8 225-0W-443-342 $5j332.31
MtT 13N FILIM1IC ?PLr3Ci i -;RR81D 701-000-255-0,) 5330.29
`J 3 •TNN 1'1, fl t C': Ex.
$7,54-734
LESS :Pi'..R-PAM FE S
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RECEIPT •
DATE
BY r _ ,� '
DATE FINALED`
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
/ — / /,
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
Drywall - Int. Lath
Final
Final �/ r�
BLOCKWALL APPROVALS
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
— —A.Zlor
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
Appliances
Final
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)
COMMENTS: