0103-074 (BLCK)'. LICENSED CONTiIACTOR 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
Profes§ionals Code; and my License is in full force and effect.
License #y + Lic. Class Ezp. Date
Date u>, P' ` Signature of Contractor
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 (SPc. 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_ ). a
O I am exempt under Section '% • .B&RC. 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.
( j 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
permlt'Is Issued. My workers' compensation insurance carrier & policy no. are:
Cartier ' I Policy No.
M VU CAN AL71 ?i3'CN:` �QA��TCA�+%�fiii3�3�9(9{t
(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-ag ee that if I should become
Subject to the workers' compensation provisioris of Section 3700 of the Labor
Code, I shall fort with comply with those'provision.��,,,� ._ w•-
ii fr 'a''Applicant—
Warning:
A licant
Date: pp
Warning:. Failure to secure'Workers' Compensation coverage, is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La .Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorsze=representatives of this City to enter upon
the above-mentioned property forinspectJi9'nurposes. 3
Signature (Owner/Agent) A �i� _ Date'• .
BUILDING PERMIT PERMTt/
DATE VALUATION LOT i� S,S'�t$ TRACT
69 4
JOB SITE
ADDRESS &V
AP N
'�
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
CIANAI3AY CIOMRANT
Y
t';M,t bA Y fir, COMPANY
174OWE , bT11.1 M, 61,06'
17480 1?1X ", CQ6
TUSIIN' f�'A 92780
fz�b'W CA 92780
;a14'i5Q8--4a40 MIR 4485
i
USE OF PERMIT
GENEIRIPS ,13TWIMTO
3;1 LK Of? 4' 91 O;LOC;i: WAL.ln 33 L.Y. OF 4' 81DCK 'WALI.
ORCYO STANDh,W), `
6 FF, '€ AILD S.t7e J.P
4 r...;% WALL, 3i #l0 I.4
F.19=ftT1111D COST (yr, V101RURKWON
2,603,013
kERVTIbM r : fi
gB'f 1,-000OO SM.WV
CONpAS6GON sRIE.
.i
SM-TOTAL;e ?P�1 "),Ridt °CkCbA7 k�t'J 7% �?,3�i' 4 ` Jw
$54.00 t
$0.00
y� �{�y7� �;+ �,1y+��y
�}yw�+,,��� 7_y�g ��p,q•¢ FE
TOTAL, ! A a44"�Q•�'sr FECES '.LP6TF 14O 7.'W
�•�.�® ��y
?9vT57rV1.7
RECEIPT
DATE,,_BK
t•,
t,P
D T F ALED
INSPECTOR
t1.
4.
_. .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel -
Set Backs
Footings Be g � ��_
Bond Beam � y� p �
Electric Bond
Main Drain
Approval to Cover
/
Equipment Location
Underground Electric
Final �Z��=� �`�
Underground Plbg. Test
Gas Piping
�l
PLUMBING Ar PROVALS
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
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
Utility Notice (Perm)
COMMENTS: