0002-046 (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
s Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
t, � ;�,, G� g i'
r
Date Signature of Contractor°
V._
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 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).
( ) 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:
( ) 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.
Is L':l; t 5"<t�D 04 f;4,1N, h,,,
(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_scras.10 become subject to the
workers' compensation laws of California and agree ttiat if I should become
subject to ,he workers' compensation provisions of Section 3700 o the Labor
Code, 1 shill. forthwith comply with those provisions. I
Date: �J'f r '°� Applicarit +�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $106,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to complywith all City, and State laws relating to the building
construction, and hereby` authorize representatives of this City to enter upon
the above-mentioned property for inspection p rpos S.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
Qft341'�'-1i46
DATE VALUATION .$ v.� LOTS TRACTJOB (��
ADDRESS 43-614 d' lsVIA Sixi,aa ,114��i
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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'i9 -29w3 f'UkNCH0 LA. QUINTA DPL
1.:1 QU1NTA 0A 92253
LAQUI NI A ('A 9225:4
USE OF PERMIT
SINULE t`.AMIM..' Li'lrV&J..1NO
At ila,! l T kX.)E,i;i X A 1 iNCLUDI I ULOCK WALL 6i�
11tJ L. i;.a1'1,.AN c't LCT~ YIrl f1tiDtJi:"1'ION Ytjlt NII)Ldlf-1t.61SSUAN ';,, (A., - 4
"AM' YL,AN TYPL. 9
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r-A)NSTRUC tION FEE 01-frf -W)- 4184M S>1.521.50
Pfj\1Q rwirm rvv 10143flf►- 11,Vl 18 `? AOR 71
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tr>wt u.ri2di�J>,19 FU, 1.61-1WO-420-ow w it,.;°1
P UNUMNO1•`3+E tLLI4*0419-ow $IM5.00
STRtitvtr MtC)'t'TON FRF Rv,-'!0 Illi-(lftfl-` +414KII) 1;3S 14
skVlti ,1.v)*IiRIMPAt>i f;ta'- $00'tmv
A10' IN''1P11,91,It. * Pf.AC hf`) _ HLiSW 701-000-2,53-(jS1U �G6°1f.4`7
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COTALVIERMIT letde.S 014, NOW
RECEIPT
DATE
By,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap��
,r�.
F.A.U.
Framing
Insulation
_ j _ �;, �.
_per
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - 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
26 -.--_A0
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
112
—
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Notice (Gas)
ELECTRICAL APPROVALS
Power Pole gUes f /�ov 1ve
Z �
ground Conduit
Low Voltage
Fixtures
Main Service
Sub Panels
Exterior RecA
G.F.I.
Use of Power
I Final I//_ '7. _ r , I
Notice