0211-045 (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
?176 4,110103
Date !, 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 -isnot 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)..
O I am exempt under Section * B&P.C. for this reason
Date Signature,of Owner
WORKER'S COMPENSATION DECLARATION-
-I hereby affirm under pehalty 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:.
Carver.n y `'"V MUlf UjUrTM'
Policy No. rt n v iYn s vea, n v�vn
(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 provisions of Section 3700 of the, Labor
Code, I s all frthwith comply with those provisions.
Date:A ! Applicant
Warning -,.Failure to secure Workers' Come nsation coverage is' unlawful and
shall subject an employer to criminal penalties and civil .fines up to $100 006a in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's'fees.
IMPORTANT Applicationis-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 application 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 upon
—the above-mentioned property for inspection purposes. +----
.,,,Signature (Owner/Agent) � ��� �^ -� Date
BUILDING PERMIT PERMIT k
DATE s VALUATION ,�./� s p LOT TRACT r
t is tlj_rf�
JOB SITE �- �r#�
ADDRESS I V Y`AOUMt 0 " f M1
APN':•
117,25D-00,'2
OWNER ! r
r”
CONTRACTOR / DESIGNER / ENGINEER
7i 71.1 FPO) WADI 0 4100
73.121 FWAi NYMM.;!Ca' 4106
P LIA DESERN CA 92260
(760)04.9699 - CBJ_6 als'32
USE OF PERMIT +
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CUNSTRU,1E0H FEE, 101!4004 8.000 sl,xaso
V11aRe CHWK r'C!' 101-00 0-439418
1-000
Rv "cKh 11ct.&L'ftP„ � 101-000421-000
9-LC:°1RICA1:2r , 101-060-420-000
P#:,'i.1MBING DEt; H. 101-000-419-000
STI3.ONr," MOTION, PET', a R-915rtl 101.0010-241.000 *27.50
(11 AD1110 Rip, . • 101-000-423-000 $1101
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CITY OF LA•QUINTA i
FINANCE DEPT.
+
RECEIPT
DATE- ABY
DA AL
IN TOR
tt. .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
Forms & Footings
Ducts
Slab Grade
6rReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans 17
0. K. to Wrap
_ _
_ _
F.A.U.
Framing
✓
Compressor _
Insulation
Vents
Fireplace P.L.
_
PY
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
v
71
Final
Final
_�` _
POOLS - SPAS
BLOCK ALL AP ROV/�► S
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
R Iry
Heater Final
Water Piping
_ _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
r o '3 �c t,
Encapsulation
Gas Piping
Gas Test
t. _
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRIC
A PRO ALS
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)
(UVV-/�,_z