0002-044 (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 # Lia Class Exp. Date
.�- Lt C 1t�Ii2bi
Date Signature of Contr,"aator�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that'l 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).,,
O I am exempt under Section B&P.C. for this reason
Date y . Signature 'of Owner
'WORKER'S COMPENSATION DECLARATION
.l hereby affirm -under 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 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 Labortode, for the•performance'of the work for which this
permit is issued. My workers' compensation .insurance carrier & policy no. are:
Carrier Policy No. ,
Aa640'
ri�•w 313
c 1.e�FrI.
- , t .II Q . .
I
. .
(This section need not be completed if Vie 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 mannerso-as to become subject to the
workers' compensation laws of California and ag're lthat if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant •
Warning: Failure to secure Workers Compensation coverage is u, lawful and
shall subject an employer to criminal penalties'and civil fines up to $100,000, in
addition to the cost of compensatiori, damages as provided for in Section 3706
of the Labor Code; interest and attorney's fees. .r a
IMPORTANT Application is,'hereby made to the Director of Building and Safety
for a permit subject to.the'.cond'itions 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 180•days will subject permit to cancellation.
I certify that'I have read this application andstate 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 of this City to enter upon
the above -me ntionedroperty f Vinspection purposes.5.
'
Signature (Owner/Agent)' Jam' C� ! 'Daae _/
4-`�' ' BUILDING'PERMIT PERMIT# .
f.
�DATE
VALUATION �j gyp: g � ,�{ LOT j TRACT '2),)30(5
JOB E .,
ADDRESS 45-®44V(�TA 64LaW11NO
APN
40=
1
OWNER .
CUNTHACTOR / DESIGNER l ENGINEER
i1T1�7 T B 7JT,'lrGr �1�J xro -v
i 1„•la 6 0. �.f4'. L+IO..IJ/v�,t
�a[ 'SSC �-eI'nTC"P•P'1101'110i 11
1,\ if lY
Flo BOX i ! !U
9 2-43 RAI Ni LA Q1Jl�i ldi SJS�
LA QtiiN-VA CA. 92253
'LA QU{NTA CA 9225-
225-(160)7'7,1-1,041
(160)771 - 1,041. C1.3-1,#
?i 1
USE OF PERMIT
$W1G',.U: h.I
.MiLY
VD -LOT a 64 T)l. it MSR- - PEi2iviz. - DOE NOT W LME BLOCK WALL OR,
I-16 11.., 75% PLAN t ilEC k. rt'f? /ltt ldt '1 EG'3J riik �11413.'f E�l:h 1.SatJAt+IC t� Ltt� �, it sfin
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psi
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t��yli,A��' T))glff,C';9 F"FF, 1014100-439-318
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EUCTRICAL, VE9
10!-000420i30ttPLUMBING
FEE 101-00C-419•=000
SMOt`1EinqOTY010FIFF. I t't`f 10,1-M -241-000 &14:1"1.
CRADINT01 101-000,023-000. 12��:it�
1 '.
GV ^l!F"rA OvffPAi r VE8 r �. $ ,�7.ijo
Att T` :11`9 i+ilt3i C'i�i Ael;;i - t2 'S1C 701.00U-2,ti3-01)0 $628.47
CQNE`r'RLYC D'O 3 Ai�1a� PLAN Q,"iFiCK
11� ?APPU401 FE EIS
WWII)
RECEIPT
DATE + _
ABY/ �(•-�
J
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Z2 —Crb
Return Air
Steel
Combustion Air
Roof Deck
/ —C;Z)
Exhaust Fans
O.K to Wrap
— 7--UU
F.A.U.
Framing
_ _� ���
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
i
Final 2 as f7
Final
ZZ—
POOLS/- SPS
BLOCKWALL
APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
.7 _
�"�
Pool Cover
Encapsulation
Gas Piping
Gas Test
9
Appliances
Final
C.9MMENTS'
�e-,C-S
Final Of
Utility Notice (Gas)D
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 ZAL
Final
Utility Notice (Perm)