0002-045 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty cf 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_ nd effect.
•=} cicens'e # Lic. Class Exp.. Date
aI i k t3;t`. t 131401, '
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 the property, or my employee`s 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). �" • ' �•
O I am exempt under Section B&P.C. for'this reason
Date Signature of Owner
u WORKER'S COMPENSATION DECLARATION Y'
Thereby 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 maintainrworkers' 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:
CarrierT9> r Policy No:
• ._ iYx 9a�E 1=.N.L!jt�%
(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 in any manner so asto become subject to the
workers' compensation laws of California; grid agree that if I should become
subject to the workers' compensation provisions of S jion 370 of the Labor
Code, I shall'forthwith comply with, those provision, : '
Datef" •Applicant
,. ,
Warning:•Failure, to secure Workers•`Compensation coverage`'.is `lawful and -
shall subjectan 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 Applicationis hereby made to the Director of Building and Safety
for a permit subject to .the' condifions 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 date of issuance .of such
permit,,or cessation. of work for'l80-days will subject permit to cancellation'.
I certify that I have read this application and state that the above information is
correct..) agree to comply with all City, and.State laws relating to the.building
construction, and hereby authorize. representatives of this City to enter upon
the above-mentioned property for inspection'p oses.�
Si nature (Owner/Agent) Date
PERMIT# �.
BUILDING PERMIT
DATE VALUATION $2,64 $-7.2 LOT - i+ }-. TRACT 9
JOB SITE
ADDRESS $-�'2�'BJ�YtD4.`t&e�l}t�QlV
t
OWNER
CONTRACTOR / DESIGNER / ENGINEER
D I:i S"E' I T -D i,•. VEL PAIL.14 T ,
SPAP K
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L_)RP
9�tt3Ti
',CA
LA Q UOITA. CA 9'1253
LA QU:lIWii 102253.,;
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USE OF PERMIT
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t' ,t,e:i0f,. `;'SY* 1%AN C.WAX- ft. ]! b) tWUC TI+JN FOR, tMIJ ..11PL f ,, ISSll'AXCE O
31 AME. PLAN2'X£!K'
COM01V, CONA STI2tiLTT033
izc�3iZ%$i/i3A tia aG.i►ti S
ifl4ttA�ii7£�fllel:a �t l.' 693.00 8F
. .. i7yA, D yyOISId 10F CMISyq.RU f -W.11 IT111
royr;6yy b►9•*'J. `9((�...
:"ieflY«Y Al l..Llt �`
w+"::)M`t ft.ilCI'10010'73 1U i-1}UU-91#L EKiU $L203.0
PLAN CMF^ 'II F;f; 'SZ.17.,07
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A101N F1LJ8.LIC 0_AC`•+ S-31EStu 101-400,2.55-(IUU
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$4,317W
.E SS .,PIPIPr1,,0 FF 117,
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�U.3,8.1.94 •
RECEIPT.
DATE
BY/(� %� f
DATE FINALED
INSPECTOR r
w r �
INSPECTION RECORD
y OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
i
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
O�
Exhaust Fans
O.K. to Wrap
�Bp
F.A.U.
Framing
X07,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Bye117
- SPAS
Final IPO
BLOCKWAL
AP ROVALS
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 LinesZ
Water Piping
-7
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
,
CIO
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 114
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)