0002-051 (SFD)LICENSED CONTRACTOR DECLARATION
I herebyaffirm 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.
Licen"e # yLic. Classs///___ Exp.. Date
J' - t) ,fit/ d} . � i3 •� � � l} lr•r Ilii:
Date fT �� �.' Signature of Contr act
or
r.. xOWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's.
License Law for the following reason:
( ) 1, 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).r •
O 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:
O 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
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.131111%
. iu.r• n J L” A'r/n.5!-11Af1.W°0 .t0
(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,
•1 shall not employ any person in -any' mann r_so as to become subject to the
workers' compensation, laws of'.,California,.and agree that if I should become
subject to the workers',compensatio�n provisions of Section 37_00-•f the Labor
Code, I shall forthwith comply with .those provisions.
Date: V/, Applicant ((�
Warning: Failureto secure. Work -Compensation coverage -is unlawful avid
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
for a permit subject to•,the conditions and restriction_ s 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 resultof 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. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize a representatives of this City to enter upon
the above-mentioned8� property forsiFFnspecttionJpurposes:, t
Signature (Owner/Agent),"„ Date
•F 41
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I O BUILDING PERMIT PERMIT#
ZS�FJ
DATE VALUATION . ;LOTS TRACTJOB
SITE
ADDRESS 49- Z%34 WSTA, 3=ft,�rt�l�7zA3�it�
APN
+ 649-10 616
OWNER
CONTRACTOR/DESIGNER/ENGINEER c'
'i'°,) DES 1 P1111*. 01 E V18111Oi'PTt3i°J .
SPARKS COT�tY�- FRUC1!(��� I.1 � y� � j i,
PO.13OX 1716
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LAE,U N'TA �,. CA.` k)�75
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USE OF PERMIT
STMOLE I`ANIIIN Mi2LUAM
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31173D -LOA '71 PLAN NO 1*1EfW0' DOES 1+50T,1XCLUDJ3, BLOCK. WA.LL
ty X)L • lSt'dtl !'Wa N 4#•D.ECh''ON 1 OR, iVt.Ll1.'1'fl. LE i,` SUAiNt,E 01•
SAME PLAN 'CYPEL
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CIRIVI 14t., FI 1014,0423^r0�'
EIVELVt 194. l.Mt'AG;'.P 1 ME
Ic Pf,1vcFS - mo,S)L' iol-orx 255.000 $628.47
N
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LESS PAUD c
9'FrRM '!' ,Ir: (.`..ES DUENOW
RECEIPT
DATE
BY/ . (
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
o/ G'
F.A.U.
Framing
Compressor 00,
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final 9
Final lhdz
BLOCKWAL A PROVALS
POOL - 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
Water Piping
sw
Heater Final
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
r
Appliances
Final
COMMENTS:s s
PP.irt J OA-- fo 'c CO/V00— S
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Finalr)4'ewr'K
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring 101,
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)