0211-049 (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).
() 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.
,Q) 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:.
Cartier UBEVY MU7"U L K Policy No. W:At2=6047W12TI
(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 shall forthwith r comply with those prov'sions.
Date: f ry . Applicantay ✓ ` ,
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. • t
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 applicatori'agrees to, & shall, indemnify'
& hold harmless the City of La Quinta, its officers, agents and?drriployees.
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 uponT
the above-mentioned property for inspection purposes.
Signature (Owner/Agents' +� r Date A !-�• 3
ZllJ_LVV 'f" .
BUILDING PERMIT PERMIT#
v
DATE VALUATION LOT TRACT
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JOB SITE -`--+� - * '—"^� -__ry
ADDRESSaMi.451
APN
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OWNER
CONTRACTOR/DESIGNER/EN INEER
T011L WXYCHTMYe,
Too., awmmuq Lq'c
7'4-12.1 DIM) WAMWIM 00
73.121 142kJlf?WA 0It",00
USE OF PERMIT
SIFC IZ, FAV3:ei Ur DWEU:3N'G'
P1.`24)R #,A PERKIT WFU3 NOT tiaL'1•I..fislr, SIZIC 'WAUA
POO'., uIP.A.Olt DRIV MAY APPRQ_%ACVt f5%,gFDW2 Y014 TO KAX CHECk
FIDE DL Z TO :. AULTIPLE,, XSS •U.dt XI ,, OVI ,",Fi1a E PIAN `I'i PLf.
.Ckjbnlom CON,iiT7♦V7,..TION ,21'V.00 1.4 p'
PORCWPATIO 435.00 SF
i+.d3�k2k�CiL�1C f4 k3�C)i�f 1410 SP
EST1MA'ful) COSIT OF CON trKRI7criON
'Ei43,0e l
i' nt' :iG: n3umwmv
CONSTRUCTION Pial? 101.000-41 8-000
p4p.H CHECK I!EZ 1U1.>000.43.9-318.
1'±4WHAWl11.1 E19 301>000.421.000
L7.8`,G`f`I,:icAJ V10: 101-000-420-000
I'X.i1:A4k1I1tiC1 E+R 101-000- 419-000
511140'"1 area+°r1r 1 r 11�•• x 3111-0l .iT�2.�1ryCifiU �a �.SI
C41At7 W YKE 301-000-423-000 lii WWI
135 fly i>OftL4I l.It91%7' I?Jt L $�403.00
ART M PUBLIC Pi.+ CIES RY.31L 2,,70•ik00,445.000
� s
A
X -%I -PAIN, T+1t05
$�J.00
tNOVL&W
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CITY OF LA CUINTA
FINANCE DEPT.
77
RECEIPT
DATE fir,
BY
DAY FINA D +.
SPECTO
y P ,
FT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
ZDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
e 7 g
Compressor
Insulation
p 57
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'j
Drywall - Int. Lath
5
Final
BLOCKWALL A P OVALS
final ell/
POOL - AS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP VAS
_
as Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
_ _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
3__. 7. d 3 <$%
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICA APPR VALS
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) �41