0301-127 (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# p�Lic. Class Exp. Date
/ate ' i �% Signature of Contractor • ` 62
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.
(��tt� I have and will maintain workers' compensation insurance, as required by
4 ction 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 IA132)!t'f y MUTUAL p: Policy No. WA20.ia(! .12.10127 .
(This section need riot 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 fo hwith comply with thosepprovis'Qns.
Date: "..X, Applicantf/ 6�
Warning: Failure to secure Workers' Com x nsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT' Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions• set forth on his
application.' • .
1. Each person upon whose behalf this application is made & each person at ,
whose request and for -whose benefit work is performed under or pursuant to
any permit issued as a result.of this applicaton agrees to, & shall, indemnify
& hold harmless the City of `La Quinta, its officers; agents and employees.
2. Any permit issued as a result of this application becomes null and void if •i
work is not commenced within 180 days from date of issuance of such'�f
permit, or cessation of work for 180 days will subject permit to cancellation.
w I certify that I have read this application and state that the above information Is
correct. I agree to comply with all City, and State laws relating to the building V.
—construction-and'hereby:authorize-reoresehfatives of this City t center upon _.
the above-mentioned property for inspection purposes.
sem. '
Signature (Owner/Agent) Date.
BUILDING_ -PERMIT PERMIT#
421
DATE I VALUATION ' LOT TRACT
30357
JOB SITE 2__
ADDRESS 10rY 1 t
APN
OWNER J
CONTRACTOR / DESIGNER / EN (NEER
TOM B.RarfQf R8 We.
'r0X . 33id.0TfWW' 1NC' ,
'13.121 kl= W KRIN . 4100
1/3.171 F'1?ID WAR210.100
CA 92260
PALM, ;1aYMi XIL C A
92260
3i<4l ld-` 69 9CB1.4
3832
USE OF PERMIT
SL4ZOLE FAMD�Y 15'W!� LIX40
SPI) s, LOT /tf SF,130NA • A, PFI"MIT 130.F3 NO T rN'C.L,"UOM OLOC K
WALLA POQ4SPA OR. DAWMAY PPROA.C.H
C 'UHTOM CONSTRUCTION 718091 Do SF
Pf;31tT.C1'UP AT:IO 21/5.00 SF
G;��[;3`'�R:EI�:�'gOiJ ?T��? 101-?✓r�Od4$�YOOf� �l,tr��„��
� �N CB9F:C Fu. 101 �a00-434-319 $99.11.00
MECHANICAL Y ..E 1014300421-000
A tAXT RIC.rAL FEE g. t31 -Opti '120-Ut30 <6tf.Z0
lalrljlM.�i3;NO FRE 101 -OLIO -419-000 W70
STRON4 twFO1'ION FFM • jRZ31D 101-00,0-241--000 $33.3'7
GtuOrwo FRE 101.000'MS 000�45.rr10
0W.FLf3P,ER. IMPACT FU &V105.60
ART rN PUBLIC PLn XES • TiESK 270.000•445,,00P $04.11
0.00
,r. 1p03 'rou"L mmVIF �FKP S DUE HONV
$Sof.)5,90
®J 4
P
C�Ff�� C�� -- .�
T---aw+-+----- ��{{—pp--�--
RECEIPT
DATEI Y�
T
INSPE
k, ti
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
A FA
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
•o ?j
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Y.,Zf -•d
2001-1
Compressor
Insulation_
0 9
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
��
P0019 -SPAS
BLOCKWAL PPROVALS
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
1
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
. 03 ,
Encapsulation
Gas Piping
Gas Test3i�
_
1-
1012
Appliances
—
Final
COMMENTS:
Final
0
Utility Notice (Gas)
�[]
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
np
Exterior Receptacles
G. F.I.
_
Smoke Detectors
Temp. Use of Power
Final
"Utility Notice (Perm)