0002-053 (SFD)LICENSED C TRACTOR DECLARATION,
I hereby affirm under penalty, �'perjury that I am licensed under provisions of,
.:,Chapter 9 (commencing with �Iection 7000) of Division 3 of the'Business and
Professionals Code, and my License is in full force and effect.
License # oc. Class Exp.. Date j, -
'Gm ni
0
Dat Signature of Contractor.
OWNER -BUILDER DECLARATION
'I hereby affirm under penalty of.perjury that I -am exempt from the Contracto(s
License Law for the following reason:
1, as owner of the property, or my..employees with wages as their soldi
compensation, will do the work, and the structure , isnot intended or offered for
sale (Sec. 7044,'Business & Professionals Code).
1, as owner.of the' -property, am exclusively contracting with licensed
Contractors to construct1the project (Sec. .7044, Business & Professionals*
Code).
O I'am exempt under Section B&P.C. for this reason
Date Signature sof Owner..
WORKER'S COMPENSATION DECLARATION
I hereby affirm Linder penalty of perjury one of the following declarations:
I have and will maihtain'a certificate oiconsent to self: insure for workers'
0 .
compensation, -as provided for by Section 370of the, . Labor Code,'for.,the
performance of thework.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" y�f7 Policy No.
V -10A
(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 son,ina , n'ry'm-annKso as to become s6b . ect, to'the
workers' compensationlaws'of California, and agree that if I should become
subject to the'workers' . compensatio"n:Provision'sof Section 3700'of the Labor
Code, I �Pal,1,91 with Comply with4those
/ I provisions.
Date: Applicant'
pl�,I,Icant_
Warning: Failure to secure Workers' Compensation coverage is -unlawful and
shall Subject a ' n employer to,criminal,l:;en'altiibs and civil fines,up to.$1 d. 0,00i$,, in
addition'to the cost of compensation, damages''as'provided for in Section 3706
of the Labor Code, interest and.attorhey's fees.
IMPORTANT, Application is hereby made to.the birector'of Building and Safety
for a permit subject. to the, conditions, and restrictions set forth, on his
application.
1. Each person upon whose behali 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 r;sult'of this applicaton agrees td,- & 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 ha'Ve read this application and state that the. above information is
cohrect.,l agree to comply -with -all . City,' and State laws relating to the building
construction, n, and h'6re,b`y' auNthorize, represent6tives, of this. City to, enter upon'
the above-mentioned for i n spiq ct i 6'n,,p U� /os el
pro!e�rt
r
Si nature 'Own n1l Date YAf /451�clJ
J
BUILDING PERMIT PERMIT#.
VALUATIONLOT 7-1 TRACT 2,9306
JOB SITE
ADDRESS 4.3-494 VIXI-AFAW—MUNG
APN
OWNER,
CONTRACTOR DESIGNER ENGINEER
WTI DIA173 1C,1_P&f8,NTL
.1A QUIN,rA CA 9,2YP
LA QUEN FA' 'C�A §2,83'.
771 1041 C
USE OF PERMIT
SINGLE FIN y 1)WF1xrK-G
AGCK U 9 Crib' Sr, b4,OT73 PLA14 M
- MERMITYPOES NaNOT TNCLOPEB11
' GrAYN FOR OF
P00111. 7$1/10 PLA34 CHV�GXJIEE RE00 �g
SAW
3 PLAN ',I Wj&
Cux Vjyl CONTSTRUI7110N 4,V3.00 e!"F.
P0.11MMM 522.00 SF
OARAGUOA"Olkl' 710,00 SF
tSRINATI ED
T CM Or! CON UIC TION
PERRIRT FRE SUMMARY
0f -0(30-e1 I 8-00o
CAT, I, —RE1-0 -20 W6.7
io 1 00-4-000
'PLVW1.1NG FW 101-000-419-000. 5205.00
5TYRONIQ MOTIONFEEr-'REWD 101-000-241-0010 $31, 14
GRADING, M -r-1 101.-000-423-000 $20.00
DEEVE-LOPOKIMPACT'FEE,
-AR.7.17 IN PUBLIC, LA0: i% RiFS.It 70.1,0004554M $628.47
$5,009-05.
'LESS PR 141AID FEES
sup,
..TOTAS, MRIVI IT I�EEA -DUENOW
RECEIPT
DATE.
BY
JDATEFINALED
JINSPECTOR
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
(10�- -
F.A.U.
Framing
!— Oma �-
Compressor
Insulation7
p -p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
r ��
Drywall - Int. Lath
—.ov
_
Final _ �'
BLOCKWAL A PROVALS
Final
POOLS - S AS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS "
Gas Test
Electric Final
Waste Lines
4g Cc/
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
COMMENTS:
Final
Utility Notice (Gas)
- ELECTRICAt 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)