9907-096 (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
� 1,4
ate ar' , Signature of Contractor
OWNER-BUILaER'DI�CLARATION
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.
^ 6) I have and will maintain workers' compensation insurance, as required by
Sec ion 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.
, 4 t 1�.1. I rLY1Y1.J
0146-i1()Lt% 1y1`3
(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 tate workers' compensation provisions.of-Section of the Labor
Code, I s all fortiwith comply with those,provlslons. _
Date:' �e'` <s Applicant
arning: Failure to secure Workers` Compensation coverage is unlawful a
shall subject an employer to criminal penalties and civil fines up to $100,000, ig
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 comply with all City;-antiState laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prop � f- owyr inspection purposesl
ySignature (Owner7Agen6
BUILDING PERMIT PERMIT#
DATE VALUATION 1i73�tS� �l�'v9 LOT TRACT ;511i
—7/ Gi)!/%
ADDRESS 1111 VIA JOB SITE/
APN tD-36 �}tl
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'..117T)ESE ft, 'i'1)EYE..LOPNIMNrr
SP:1.i2:1:SV NI.TfR1X,"1`RON
PO BOX 1716
79495 "NCHO LA QUIM-A Did
LA (1.li[i1'1'A CA 92253
LA 440iXTA CA 92253
(7601771- t 341
USE OF PERMIT
al.Nf, AAA ;F.AMJL8' D El.l.i�lt�
Ski) -.LOT 37 PLAN V:23 - PEMAiT DGES NOT INCUDR ii1.Ut;:r. WALL
URPOOL, OL, 751 o :ALAN t:l'1EkX* F& 1"I JUl'[ON FOR ML1Lt t iPL,::
ISSUANCI- C14. MUIR PLAN `I'i'i?.
CUa OXI c0143"TRIX'17TO s 07414) 3
QAI:(A, iA9CARIX)Xf 617.01) W
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173 Z .119
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i'lle-R 111[ ��� IFI S1il11Li AR'N"
("ONST( UCtION FEE 101-000-418.00 $898.50
Pi I AN MR04 FF F 10140-09-11A S 118194
NT01111.NICAL f1li"; 101-000,41_000
R fit:Fk(CAL f .f„E 101-000-42"00 S03.43
1aLIMN4 INO FEE lU1-Uf)t?-41t7-{1(1(1 514:3.2.5
S R 0140 00(T1"dO N 9ti:. '9!77-511111t 101-0015 -?41-000 S! 717
0ftAl) IN0 f -M4 C; 101 000 _4?1.000 S24.f3t1
t4i�Itt�xlfttic��1`t�ttE.ifits M-(1fi#1--13-i42 i:3.yftr_3if
AWI' LN PUBLIt''PLAC.'i3`i r I"- W 101-000-15-OU0 $18414
;tii,fl3M-Y AL (".0N,;('it(,T( 1"0N A,N 10 PT ,AM Vff rCkK
SS,S65 R1
USS ME-PAIDRES
$0.00
`.I'sl`("AL 1PERIP41fr FF. 00 F,NOW
55.565.83
RECEIPT
DATE
BY i
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS .
Set Backs —
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum"Air
Steel
Combustion Air
Roof Deck (J •
Exhaust Fans
O.K to Wrap
F.A.U.
_
Framing
Compressor
Insulation -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
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 d
Appliances
Final
Final - Gz/
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) �.-
COMMENTS: