0211-083 (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
1776919 B 44 a103
Date �� �' 1- Signature of Contractor"!,`�'�
' t✓
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.
14 1 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:
Cartler I ibLiRi—y kiUTi.ilki y Policy No. `T' 30`2D 94;»^111I TI.
(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 Y R Rhe workers' compensation provisions of Section 3700 of the Labor
Code, I shall forpwith comply wit hose�J�rova ions,
Date: 1 'Zi .�a Applicant_ t'�-9d
ti
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 ai
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. l,agree to comply with all City, and State laws relating to the building4
construction, and hereby authorize representatives of this City to enter upon
the-abovd-mentioned property for inspection purposes. r _
.Signature (Owner/Agent) /` ��'f �° """� Date%�
BUILDING PERMIT PERMIT//
�
DATE VALUATION LOT 1 � TRACT
1. , - _ 303,57
JOB SITE _
ADDRESS - �8.�AI<t (�SA
APN
']72^„Z.�ri� T
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
73.123 TF.f wt WATa—*1 #100
7312117M.)WAhM 0100
.PALMDF.SERT CA 92260
PLIV.14,I?:i;Zw VA. 92260
(16a4`)674.3699 C:,�3,f 31333
USE OF PERMIT
SM - LOT 19, SAN Th IZOS9 -'A, PX9441'1T'DOES. NOT 'INCLU DZ BXZCX
IYALU% $roo Otn SPA OR DRIVEWAY LAY i{3.1?.E"E OAIC H
y
CUSTOM CO1d3TRUC7101 3F
Pt3.RCkUPA11I0 3' i1.US't
43AR. GRICARPORT `tSa,Ci11 aF
' E6TINA' 'ED C019r'a1' C0T14TX1?.liC,110ni
m.0,;,%70
VI bullF7N:E90WMA:RY
MAS`1RUCTION IMP, 101-000-416-000 °ip7a.00-
fi
P.t.r,NCHECK t"LP "lq$�crG}t1�4a� i�4 �1,IIit.7i
-<
MECHANICAL NIC;AL FE1a 91191130
ELECTRICAL ".F, 1 tJ1 _000420-06110 9201.06
PLUMBING FEE 101.000.419-000 $190,00
�
S'CI;. N0 MOTION F -L?. - itFSID 1:01-000-241-000 $71.06
' 1
G&ADING FSE 1,01-0,00-423-000 $15.00
DVELOPER R IMPA( a' )ME $3,,4118.00
ART IN PUBLIC PbAC ES -MEI 2704-Cli 0.445-C, 00
N i M
Ai
Y•. � � Y 4T �•r•7.1
����yyyg9999••• •qqqCyyytvppp, nA ,t �•�, n� a rw l� •�� T AND'[j f.(.'��:tl:�(MJWKI
.i.C:ic...i.�.l'JAV ta[V
�`LtiScJ({
.��ybn�a'�Cj..
pl.'•�lY,.av3At
1`• Lr.FZ
.•�j �.W�R--�.•
�A!w+.
((((({[1
{ 7 spy ®�y,gq g�g�vg �+,+/{,�p�6� {f�P�`�s
YW
]Lf .!:.�•ri.TstYL\T ,&:t S DVE NOW
2
Q�p� rypq.q
9r.T1 l.irCFndY�
Nov,
CITY OF LA OUINYA
DEP'`'
FINAPiCE
RECEIPT
DATE
BY� -
DATE FINALED
INSPECTOR
j 4' c"2,
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
7i
Exhaust Fans
O.K. to Wrap
o 3 S7
F.A.U.
Framing
(D -357
Compressor
Insulation
_ c
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
6
Final
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
I
Gas Piping
PLUMBING APPR VALS
')-
Waste lines /
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower PansO.K.
Sewer Lateral
_
_
for Finish Plaster
Pool Cover
Sewer Connection
o3 S7
Encapsulation
Gas Piping
Gas Test
_
Appliances
71
Final
Final 3-5
Utility Notice (Gas)
W -S=
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: