0002-049 (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
674074 07i3i r201
Kof C
Signature Date' Contractor
OWNER-- BUIE'-D
DER'E"CLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, as ownerof the propertyi.or my employees with wages as their,sole
compensation, will do th6 work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, 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-insur.e 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 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.
'S1'1101.3 11"'UND
(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 personih any manner so as to become subject to the
workers' compensation laws of CAliforga, 'and agree that if I should become
f`S
subject to the workers' compensation pr6Visions o�ction 3700 Of the�Labor
Code, I'sha/11 fb/rthwith comolywith those provisions. ryr
Date: 4g1---2'"-A0pIicant_
Warning: Failure to secure W66Ze—F8 'Compensation coverage is unlawful and..
shall subject an employer to criminal penalties and civil fines Lip to $100;000, in
addition to the cost of compensation, dar-hages as provided for in Section 37061
of the Labor Code, interest and 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 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 d ate of issuance of such
permit, or ceisatiori of work for 180 days will subject pe , rmit to cancellation.
I certify that I have read this application and state that the above information is.
correct. I agree to comply with,411 City, and `State law's relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned P'roperty foy'n'spection pu'rpose5,_
Signature (Owner/Agent)__,_ Date
BUILDING PERMIT PERMIT # ' 0002-049
PITE.) VALUATION LOT TRACT
JOB SITE
ADDRESS 49-574 VISTA FALOAHNNO APN
OWNER CONTRACTOR / DESIGNER ENGINEER
Irl -N 1"V174Z110111
4. 1 %�o L 4
4 LX " 4i V.- A LI.0 V V- 40 'V %_11
PO B0.X 1716 79-295RAINCHO LA QUI
LA QU191-A GIL 92253 LA QVIN TA CA 9215,1-
(7'0 0)77.1-3.941 C13I.ti -42-996
USE OF PERMIT
SINGLE FAIVIRX DWELLING
SFD�LOT 69,11LANIVORG- PMJV.dT.D0E3 140T WLUDE, BLOO,� WALL '01t. �0
INWL. 7SIN PLAN CHECK FEE --E Ra-)UC716N FOR NIU: 11. IS'SU'ANCE OF
SAM: EPLAN'I'VTIE.
CU S-11- GINIC 0 N 51,11UC T 10 N '11.2,43.00 TF
110na3;lPfff3o 522.00ISF,
UA1tA(_491CA1: P0R.T 710.00 SF
ESTIMATED COSTOIF
CONNST RUCf 10N
KIWI'tt"T FEE. SUMMARS,
CONSTRUCrIUN, FITS
101-000-418-000
SLIY21.50
PT. AN 0-!_FCK. !T17
t4tr1l 1ANUCAL 1M.1,
10111-000- 421 -000
$ ". 3, 6. io
tLECTRXIVII
M-000-420-000
$N(Oi
101-000-419-000
1205.00
IATRO'N'0 NKYRON F1717 -RJR9fD
10! -000-24!-0 0
$35, 1.4
D T NGV 0. 17
101-000-423-000
MME110P M WFIACT PRE
$1,%7.00 .
ART IN 4 U8LIC Ill. ACES RFMC 101-(1 O.255-000
5628.47
SUBIr
MAj, CON -ST RUCT I[ON _ANO PIAN CHECK
ni'll" ').AID
ES, }'E2
F 01 *A 1 1, r X R IN I to.' vmElsly(t P: "i<
351,33'&3-0
IRECEIPTE�Y// / _ I I
I DATE I DATE FINALED I INSPECTOR I
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
.pti
Exhaust Fans
O.K. to Wrap
. 7— S_
F.A.U.
Framing
Z &
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T:O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
AIN
Drywall - Int. Lath
Final
BLOCKI A PROVALS
Final
POO - PAS -
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
Heater Final
Water Piping
7
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:
'pi'c2,5 0 ,-/C S——oma