0002-054 (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 _ - 'Y Exp. Date
67404
r , _
Dat e'! ' } SignatuKeofCont6ct5tr,
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 clothe work, and the structure is not intended or offered.for
sale (Sec. 7044, Business &.Prof essionals'Code). ,
( )" I, as owner,of the' property,':am exclusively contracting with licensed
contractors to construct -the project (Sec. 7044; Business'& Professionals
Code):
O I am exempt under Section B&P.C. for this reason
Date, : - Signature. of Owner
WORKER'S COMPENSATION DECLARATION ,
I hereby affirmunder, 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 forby Section 3700:•of.the Labor Code, for the
performance of the work for which this.permit is issued. ;
( ) 1' 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:
Camey e.rr��iTYf� , x ,Policy No *�, ` c nom- , .
330
(This section need not be completed if the, permit valuation is for $100.00 or. less).
O I certify that in the performance of the work for.which this permit is issued,
I shall not employ any person in any'marinerrsso as to become subject to the
workers' compensation laws of California, and agree that l-sbould become
subject to the:.workers' compensation provisions Section 3700 the,Labor
Code, k0alhforrthwith comply with those provisions':
Date. 'Applicant �—
Warning: Failure to secure Workers' Compensation coverage is -unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,.in
addition to the cost of compensation, damages.as provided,for in Section 3706 '
of the Labor Code, interest and attorney's fees.
IMPORTANT'Application is hereby made to the'.Directorof Building and Safety
for. -a;• permit -subject to the, conditions and. restrictions,set forth on his
.application. .
1. Each person upon whose behalf this"application is made & each person at
wFiose request and for whose benefit work is performed under or pursuant to
any permit issued.as a result of. this applicaton agrees to, & shall'. indemnify
'& hold harmless the City, of La.Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application.becomes null and void if
work is not -commenced- -within 180 days from date of issuance of'such:•
permit, or cessation of work. for 180 days will subject permit to cancellation:
I certify that I have read'fhi plication:and state that the above information is
correct. I agree totcomply with all City, and State laws relating to,the building ;
construction; and hereby authorize rept sentativels of this City -to enter upon,. .
the above-mentioned property for inspection purposes
Signature (Owner/Agent), Date
F .4 .... PERMIT # -
_v
=, BUILDING PERMIT mou,54 ..
t
DATE VALUATION • b.2f"i$y4)J7,20 LOT TRACT 29306.
JOB SITE : 443-4-t'A i:9A-1,PALOMINO^'
ADDRESS_.
APN /7 59-�•� iWA%
OWNER
CONTRACTOR/DESIGNER/ENGINEER
•q'i'..� �d .iii,:" t'+. A' 1aii' V.K:. l0 i�P A�1111rr
9r.5.R�,iS r:-
Pur P.O.Q.1716
Pq f
� - itt11`1C1 f,�l CrUtMU. DR.
1 A Q U 1W A. CA 92253
LA. t; UINi'A -` CA 92Vg31,;*
it5,Q)771-1941
5+ '
��'3^`.; b
USE OF PERMIT
�,.Illi��1.� <§�A�t'1,�j:�;�• 1rd•rA�'1 �,1i�l�,y . �
• .�
w1 U-.1 O i 7ailk 1{l0� `.1 DOES �tQ i lG1:iTDis' iia. •,i� VJ.IiT d. fJ
FOR. MUMPIX PIX )SStdANCE 0
SAW OLAN, 'f YRTF. r A.-
lfJ;yTOM, COY>i aIMUt,.d 1014�. �,1�ifU.Q{�:9�'
• .. - ..
GMA.WEAQAitti�0111' 693.0 SF
G, "I 'IE � <.r r r rgs�r.Yel.
' Jf�+A�sA A". i!.YJ, �.iiU¢ �yJt °,. a1'�•7�OF;i.%V�6..a.d�.f21t
"
2161119p � a'
- .qi'N. /.10
i c U NYSTRUC'1: TC,)N RkX- 101-000-41"00 $1;2031 k)
LAWCHKI .t'ER
Mi•JA 11%AL F 3 1 C 14`..00- t21 J00 '$124.00
E•t.l.rCIM CIA AE 1t�l-ti12t3-42Q i1�J. �Gfi9_S�
_
T'1,MI. BING FEF 101-000-419-000 $:1ii�t.00a
-
3 £ C?ri43 fM:t DTt N FEE, - RE -SA) 0 . -t3t. 0-24.1-000-
GRAD11v* FEM ''101-000-4213-000
J)Finacipa11vi1AG'.t nx.', SI,x?':tu)
a
ART 1.Ar PUMA,"PLACES - RESW 70.1 -000 -?'55-000 ne
--
,t t 13 ^ 0T � U CONIST 2 C� ?'t AND PLAN CHECK
$4,317-97 ,.
LE SS PRE -PAID FEES
,
U10.00
.off-?TAL PEA -MAT 11".F3FS DUE NOW
`' $4;3l.7.97,
RECEIPT.
DATE
BY/ "v �
DATE FINALED
INSPECTOR • �-
��.�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground -Ducts
Forms & Footings
--
Ducts
Slab Grade
5—
Retum Air
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
/Z "off
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
j p�
_
Final
Final
_
POOL -S AS
BLOOKWAa
A PROVALS
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
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
G7�
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)