0311-019 (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
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 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). r . .
() 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.
W, 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:.
Carrier L-1D�.XT .':ItiA JTVAI, X Policy No. �' t �20�D094'71301 � 11
(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 provisio��of Section_ 3700 of the Labor
Code, I shall forthwith comply with -,those provigions
Date' ���/ •r' Applica�nnt_._.
Warning: Failure to secuYe Work r�-s' Compensation coverage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost:bf compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit -subject to the conditions .and restrictions" set forth on his
application.
1. Each person upon whose behalf this application is made & eac -RR• erson a
whose request.and for whose benefit work is performed under of �u tsuant tob'�A
any permit issued as a result of this applicaton agrees, to, & sh li,Qndemnify
& hold harmless the City' of La Quinta, its officers, agents and emaloyees.
2. Any permit issued as a result of this application becomes nulLhnd void�+if v
work is not commenced within 180 days from date of issuance hof such'
permit, or cessation of work for 180 days will subject permit to •anceilation:
r,�olt'O
I certify that I have read this application and state that the above i formation r19NA
correct. I agree to comply with all City, and State laws relating to the building j
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection pue: ses. y
,/r • ter. _ � ��
Signature (Owner/Agent) 'F \ �� :�` Date
BUILDING PERMIT PERM'T#ot�►
DATE VALUATIONZ t
ai+S��.R�.i:: �.�..�� .LOT �t � TRACT 301,57
JOB SITEft�•.� w®`;�. ��i�Lk1tl
APN
ADDRESS
OWNER -
CONTRACTOR / DESIGNER / EN (NEER
11 LL.1d'21C;THERS 19C`.
? 1 '.21 NUKED `t1vAR.R-11(3,0100
7 121 T^.CiEE 'WJAR114!f i$l0o
PA',,'14 DESERT CA, 9.2260
1W.U.. DUERT CA .9226
ivl6g1G749699 CnUf 38132
USE OF PERMIT
tl��r'.•4•i•1Jg�\:r{LstYt}/.�.G.;9.:/.6[utL BA�,,Yt\pJy�r+t .�.'pY/,.•.e..,pt av _ ..
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C"U,9TE.-M ?.5 42.00 OF
QAAAaOI':i `ARNORT ... fll.6at Sty
4,",XNSTRUC';''1CRt i FIX I W1116 0.41 F-1000'
%'.iI+' xlAl<f1:7AL, VT16%•1016. 00.421.0 0,
��,.��.�T7�1C..oi��px�.�: 1U'0.•�e1ti-�12�••i7f)u `3:1��.�9
nsFmiumo aw $221.25
.
r�^{ -M NQ idit1VOW. MiD 101_0Z-24.1.-000 .
0RADI7•iCi .FRE i . ioi1 k 4,o-4,4iss^t:10(l 1P1S,E1t1
1.YWt?i.OPER 111x, a QT IME 7C,4ir .t►ii
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0 LESS PRE PAM Yl M
50.00
19 2003. ��+,X.;I7' cs.Yt NOW
,,"t31so
E `iE11TA
XF DEPT.
RECEIPT
DATEBY
DA E MINAL
-7
INSP{JEC�T�R
.A9 . B
v /� -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALA
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
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
POOLS - SPAS -
BLOCKWALL
AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines_
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
A,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping 60
A
Gas Test
Appliances
Final
COMMENTS:
- - -
;
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)