9907-095 (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 - Exp. Date
U+=1) <���3 �:��
�� ) O
(Date J Signature of Contractor
' OWNER-131.1111DERI`6DEC_L�ION
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.
0-It%^i IV,11)21-A3
(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 as' to. become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisio of"Section 37000 of iii Labor
coder snalrfart with comply with,those prr isions. "
Date: 1S/7 0'} Applicant '
-Ile1
Warning: Failure to secure Workers' Cofn/pensation coverage Js. Lin lawfUand—,
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided'for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quints, its officers, agents and employees: .
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City and State laws relating to the building
construction, and hereby au`h.orize representatives of this City to enter upon
the above-mentioned propert%yfor inspection rpo es. L_'�e
,,Signature (OwneAge �j • f Date
PERMIT #
BUILDING PERMIT
9907-01
DATE�.-�f / VALUATION 87y681i.4 LOT � TRACT
25154
`
JOB SITE
y �h ! a,a
ADDRESS /79 -US VIA Pi'I,9rAe�. WIA
APN
646-323-009
WNER
CONTRACTOR/DESIGNER/ENGINEER
`1'''111yT?QCtiU`(` i`19'iJi7T !�' 1)p,S'CI+;1"i''
��A•i3l�6 J"�f"s'tAtC':'i3'rTJ'"t`iJ`�i�t
lla\k i.S.i.a,14. l.ak/1
b y'. lJ wei)uta, l I-1 ai a•.R%-.t. .t. )1a.6.S'! i
iJk .J 41yJ431.1
PO BOX 1716
79.295 1RA'1bJCFi_) .1,A QUl�1'TA DR.
,
LA QUft4TA. C A 92253
LA. QU.1$vTA CA 9n53
(7f,1)77 -1941. V%,— # 2996
USE OF PERMIT
SM-) -LOT 56 "P'f. iW'" 3P, -11E, RMIT.i OFS NOT INCLUDE. BLOCK Wk .'L
Ut2Q'C)(51.. ..f�i1.E:(;int.11k:1ti�L'fK}t:."1.tC;i+i+f:Nt�;(�.il+L.t1LF'i'iisl� '
qi�AK4� , F, l it °dist: H-W4'I YPO,'. -
C.'Us7't3m c,..cros—f 12.l;LT;ON 2,M.00 SF
X482.00 sr•
'
'E's Ton"mBm l$a O8cans kicr'SrUA
137109141 1 a719141u! !
Y0R4. IM E 011Nq R
C:ON11T13tT7C."'s,'10N EW 101:-000-418-000
_P LIM 096 CK FFE S19313
Nld Cat1AHICPJ., FL76 1014.0 0-42.1-000
�.1.tsG"i' MCAL : k* �T ifl1-040-i'20.OW 1 ��
Y1_tA�I NG FRE, 101-000.41.9.000 Sl 56.50
L3`i`RON% FEE - 311D 10 1.,0000 241-[t O
ORAD NO Fli 101400-4221-000
Ll -R 1, rRUCTti ulf FRE, 225MO-443-3$2 U.222.85
' 1' l�f '�1T14L1.�C'!>f,ACES - IZ�S:L'C "i0;1d(3Ui1-2.5y•�ix? $3d�.2i
LESS Ptd.I:Ta D FEES5.
$0.00
1''t-'��•p��
��i,Q7;i NOW
�yAp�p FEES
.0(.8754�A� H'Y`.i9,0ils.G� F7;Bi>RJRyII.i.t�f�.3�Y
aD{��lYys:i.ValG
Ari l '
RECEIPT
DATE
BY /°/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_ LG
Return Air
Steel
Combustion Air
Roof Deck
(J - Z'Z, ,
Exhaust Fans
O.K. to Wrap
Framing
�- _ _
F.A.U.
Compressor
InsulationCI
—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
; Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Gr
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
— — j
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
Final
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 — _ ev
Utility Notice (Perm) R/W
COMMENTS: