9907-097 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
f— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
LO
o Z r D e? ` f` / Signature of Co-Mractor
m 0 I
J U OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
O
d Z WORKER'S COMPENSATION DECLARATION
O C1 I hereby affirm under penalty of perjury one of the following declarations:
U') H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O _J Q performance of the work for.which this permit is issued.
C3 I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Ili 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
V
J
(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
3 subject to/he wrkers' compensation provisions of Section 3700 of the or
Code I shall fofthwith comply with -these provi8i6ns.
DateJ� 1�'�- Applicant �//�
Warning: Failure to secure Workers Cofnpensation coverage is unlawful and
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 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, and State laws relating to the Building,
construction, and hereby authorize representatives of this City to enter n
the above-mentioned Zntf)�
ertyfo nspection purp� ses.
E�S Ignature (Owner/AgDa 'p r'
PERMIT#
BUILDING PERMIT 40
"07 .
DATE VALUATION `11� ,{3S �;� LOT TRACT ASIy
ADDRESS 70 Y �i 13LL�t 3 r JOB SIA
APN Q► . -�
OWNER
CONTRACTOR / D�ESIGNER / ENGINEERS
•l �I Ij 9.t^, l*1, P.I �,4A-.1 JAiA-ti44R•
Ni ti►I VS fIf YNI k-ff)( f -f t).J
R)130X i 130
79295 RAMC LIG LA QLIIKVA DR_
,(,A QUIN 1°A, CA 9225:3
LA QU"IN°IA. CA 92253
(7ti!?)771-4941 9%
USE OF PERMIT
S1N�ik.�s Et�1111i,`�S' F.tl1/,��,,Lt1�Rl_I
ib - LOT SS PLAN V23it. - P i",if`i DOWS NO j!"U'Lulk, t9.LOCK WALL
OX POOL. 75% PLAN CHl;,ti.'f 1, El .IdiUUCa FR )N I;Olt. Mil(.1TH;"
1SSLfANCIi OR SAA)E PLAA1
CfU,`T OIXI CC1MS'4Ri2C 1710 t 3,074,00 Sig
f3tiFLACYWCARPuA<f ; 617AK) SF
JM7��b'i9�1AI 'D L,1LlA!T 0 1rCONSTRU'[,M.10
}}IY�►I°GY �
4vI
4°CRAUT FER SUMMARY
CONS'eEtUC-110N FEF 107.-000-4184M 584;3,50
PLAW (", K1r, CK rFF 1014)W419-3118 419-318 5 i Ir...f3
$(71'F
F11C`1`1 ICAL.FFE 101.000 -420 -OW Si43, 3
PLUMFs1NO FEE 101-M-419-0010 3)43,23
`47'R0W0 NIOTiOWFI-.ROS340 $ 7.17
G ADWO FIM, 101-000-4211000 3'«).00
JN IFRA.S1'RUkL,' i.IKEIt . 225 -OW -44-10,42 $3.9wf,lo
AW1 IN PUBUC PLACES - ttMW 701 01 I -255-W) 184. M
SUB-1'i'fTAI , CC')NC ?TY-' 0N1 A.NY–) PI A-3 014f,C'K
LESS PRE P111.1r)
"CfYI';AL V33RR! Ff F t+:.0% WIF'.?ti(9W
$5, 6S.8J
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs — .-
Underground Ducts
Forms & Footings L
Ducts
Slab Grade 2 _
Return Air
-
Steel
Combustion Air
Roof Deck _
Exhaust Fans
0. K. to Wrap - _
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
Final
Final Gc5 G
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 ex.
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines .. 61
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 G /
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
Utility Notice (Perm)
COMMENTS: