0306-048 (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
04/30W
Date F 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 (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
() 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, bye Section 3700 of the Labor Code, for' the
performance.of the work for which this permit is issued.
(i ;) 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. afe:
Carrier i IBER.TY hILSTU.AL V Policy No. TVA2i;. D1, 09,1301211
(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 Sh II forthwith comply with those jrov�sns,�
Date: ;` Applicant�:�
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 andSafety
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 undertor 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 upon
the above-mentioned property forinspectionpurposes.
I ignature (Owner/Agent) {Wr%+'!�'��%-tee �2^w-' Date �' i/
BUILDING PERMIT PERMIT#
h3 Vit' -ii
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS �aSiNyu w of.. A..j
i r�..4 1'30^010
OWNER
CONTRACTOR/DESIGNER/EN INFER
P0111 1; NC�7 : > ~? :t 1 MCI .
'�r.;t:, R. t.) f i:R ikrc .
7 W3 'II'V EC WFstdING#10_0
USE OF PERMIT
`F b4%P��lyI1fII 1}d`I'FfC`t ' tn";'`t:rF?a'plf��a`t'q: �'IgFIi�Ryi'z ''�ty0 PS R%�Yr
++t�6�llff.{{:ls{{ pn� e3y+7
1144 RT:.ri dir Y9AIJLa �'�ow" i:iPA
,SUM
F�Z9Is,f"i�'if4`.l�l',?"SOI .. SG.Q't1 twF ,
fS7Y? :€al iE:OM7 Cyr;'�1�1�a�:tifC°"l'3i:3�
�1°0;t+VJ71ZVJC:'e1V M THEE 103.00('A-19000 sly.! °x i
G';a, 1: s tIt►°^Q;: I?u ` t11-fKLO-439--??'( 3 _ s.i,156.93
mwflZ 4.111f."•m� uu, '01 -000 -424• -OU
1?`w,.F.iL:•TR.1t:A,{,..• IE't%w. . (a 30 %VD&I.1%,
101-000-41 9-000 91S�C,fis1t.
S!'iI.C)NG %MTION PER,, RESiD '10 i-I?001' 242 -000
ORA.iDKO ti 1i?:1- I3Ci�4a"� �at:y;; I�.tfr9
DJr,VE1.,0.1TH,:3 VNPACT PUP.
ART rAPiI1ALIC- PILh.CFM 'PL&W 270.000-!44:5-Ut:J SA0,73
,
A'yIY�n3�.�rv�
• t_ , ,«d4:11�A� Ci ti.'.`.•i" �.Sd..o .f7,1 .a4
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r10:1003 '
'CITY OF LA QUINTA' `.
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RECEIPT
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BY
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IN ECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
Framing
/
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls Ki z
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
final
Final J&
BLOCKWALL PR &ALS
POOLS - SPAS
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
Heater Final
Water PipingL
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
i
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: