0210-205 (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
4130.1n. 3
Date ! Signature of Contracto����
r r
OWNER -BUILDER DECLARATION
Ihereby 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). '
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
'WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaltypof perjury one of the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, asprovided 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:.
Carrier 1ADERTY MU TUAL F: Policy No. 'f�3':�dM472130.42'r1:
(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 11 forthwith comply with those provisions..
Date: -.y Applicant , Ep. �✓
�tr
Warning: Failure to secure Workers' Co pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each persona at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &•shall, indemnify
& hold harmless the City of La•Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void ,if
work is not commenced within 180 days from date 'of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon,
the above-mentioned property for inspection purposes.`'
Signature (Owner/Agent)r5� Datee J
to
DATE
JOB SITE ` f
ADDRESS S
OWNER
-BUILDING PERMIT PERMIT#
� �rS7
jt t VALUATION 1 ii D� lF3 .LOT --- m—J TRACT0357
APN "
/DESIGNER/ ENGINEER
mil, F.;,fzal"t TERS F..x! C IOL -11 ROTH Mei 11 19C
74 923 HOMY LXM, FUNBT' .1` 2420 74.9233 HOV'E'LY TANE'EM"T SUIT,
P..A.1:bI DAV.E19.f . Clk 92260 RALM DENKE 'C i".% 0 2"d��: .
USE OF PERMIT
Si•+i) - LOT 17 SAMIA Rx= A. MR -MITT 110i,;S WV1'.rMC:;. Un. E SWt' K
WAL1,5JOWL,, SPA OR .DRIVEWAY AN raACH
CUSTOM CONS`E'RUCT101$ x,791.0+0 SP
+OI?,Ci"Ilia 01110 321, Ott SF'
GATiAOl?tCA3tS'CaWC ^M, A 0 SF
ESMYA1XV Wt tY C{MARU"ICN
31.0,^.;7!
NUVyffiR71 ggmmy ,
%il 8-000 $0W.0.4 .0.4
- -
PLAW CklEck mr, 101-000-439-318
MK;2Trlyy�yyl�.l�/l�Cp:/1 "PKI 101^//C��f[�3y(?yy-421.000 ;
�$118,00
X'Lel]eCTK,1C�A,L. F R IP, 101-0 00420-000 ,p3EH� f�ii J
1, YaFwf lltdDiA1(1 RX 101--000-41 9-000 I ti.t�0
t11# 1 1'rJt }t1�li 101.000.423.000 $15.00
,WELOPl tt FrIE IA405.00
�'AIVII ria PUBLIC PLAC &I -, ;P=K 270w000-445•000 M.39
1130 PRV_rV1>FHI0
$0.00i
OCT 31 '
Y2UO2T-a .s as ,�_? ;K91 HOW
I 1
CITY OF LA QUINTA
E. FINANCE DEPT
t.
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RECEIPT
DATE
BY
D E FINALM
SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
t/
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
R
F.A.U.
Framing
Compressor
Insulation
, , a 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
C
Final
r
_
Final
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
Gas Piping
PLUMBING APP VALS
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.
p ?'
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:
TV2/x/37
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