0002-028 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury.that I am licensed under provisions of
Chapier 9 (commencing with Sktion 7000) of Division 3 of the Business and
Profe;t-;Z-r�ls Co , de,-anclmy License is i . n full force and . effect.,
i se(# Lic: Class
L cen Exp. Date
rfP U 14,
Date Signature of Contractor
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 t - he property, or my employees with wages as their sole
compensation, will do the work, and the structure is'n9t. intended or offered for
sale (Sec: 7044, Business & Professionals Code).
11 as owner of the -property, -am exclusively• contracting with licensed
contractors to construct the project (Sec. :7044, Business &. Professionals
Code). -
1 am. exempt under Section B&P.C. for this reason
Date '—Signature Of'Own&
'WORKER'S COMPENSATION DECLARATION
I hereby affirm 6nder.'pe . neilty-6f perjury '6ne--of--the following declarations:
I'lhave and wiil,maintain a 66rtificatb of consent to self -insure for workers'
compensation,, as -provided for by Section 3700 of 4he Labor Code, for th6
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-iss6ed�,My,workers' compensation insurance carrier & policy no.'are:
Cagier .-Policy No.
c'T 6733'
(This section need not be completed if the permit Val Liation. is for -$100.00 or less).
I certify that in the performance of the work for which this permit is issued,
I shallperson employ any in any manneT -soas to become subject to the
workers'. compensation laws of California, and agree that if I should become
subject to the workers' como6niation provisions of Section 3700 of the- bor
Code, I shall—forthwith comply with those pr6visi6hs.
Date: yl'/ /100-ApplicanL
Warning: Failure to.secure Workers' Compensation coverage is unla L I and
shall subject an employer to criminal penalties and civil fines up to $1100,000, in
''
addition to the cost of compeHsation, damages as pro 1 f0r in Section 3706
o I
of the Labr Code, interest
terest I and. attorney' s fees.
IMPORTANT Applicati&n is hereby made to the -Director of Building I 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 and4or.whose. benefit work is performed under or purivant to
any permit issued as a result . of this appl�icaton agrees -to, & shall, indemnify
& hold harmless,the City -of La Quinta,its officers, agents and employees.
2. Any permit issued asa'result of,this application becomes null and void if
work -is not commenced within 186 days from date o'f'issuance of such
permit, orcessation. 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 representatives offhis City to enter upon
the above-mentioned. prbperty for inspection purp'oses.
Signature (Owner/Agent) Y
PERMIT #
BUILDING PERMIT
VALUATION LOT TRACT
DATE 48 29_W)
JOB SITEAPN
ADDRESS 49.5-57VIST APPALOMINO
OWNER
CONTRACTOR DESIGNER ENGINEER
r"D T DEV 01 L0. N,
XAk,"J;, %,., A�4,� L'i
CD "t 0110 Pnxvz6tv�uc"n-m
PO BOX 1716
79 .1-10, Uk QUINTA DR, U
-29.5 RANC
LA QUI NTA C �A 92253
LA QUII-ITA
CA. 921W�-
(760)771-1941
cm,L6
USE OF PERMIT
SING11' PAM Y D* BLUNG
&'.M.LOT -18 AMAN Mift'� P�MCM.IT DOES WOT Nfa.UDU BLOi�k NWUL OR
I FEE REDMTKYN 1�-'OR MUVrIPLE ISSUAINM OF
PL IMj<"
�A
SK&A-E PL i�N TN"PS"
PolkCHIPKM SP"
0A1WJ1YCARPGR!1' 693.D03F
CONT OF "E'UNSTRUMM"')
P E; R tW r! i F E E 8 VWM, A'K-V
CON ST RI)MONFE-NI .101-000-418-000 31,203.(X)
V. L A N'(73 +_: K 'SES 0! -(*()-4:3'x'-31.9 $ 47,07
.&MCIIAMCAL FIX
ELECT WCAL FEE.
101.00-41MOO
5TRONO W)"110.IV F"813 - R!5�Sib 10.1 -00-0-24A -10M $x"
D11 V1151.0PER Imp hCT -a S1.907.00
AFT IN,"PUB LIC; KACBS - RIESID 701-M-255-000, $402.29
�InVrorrm, CONISIRIJIG-r-ON AND PLAN CHEX'K
rRAIDHES
LESS � Pr% -
41 .00.
0.
f(.YfA.L-,PE9M1T IFE DUENOW,
17.97
RECEIPT
DATE
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
Insulation
61
tom-
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
f4 / -
Drywall - Int. Lath
Final
Finad
BLOCKWAIZAL
113111W.11AI
A PROVALS
POO S - 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
vv C
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
03
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service `
Sub Panels Of
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final Q
Utility Notice (Perm)
COMMENTS: