0307-154 (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 Businessand
Professionals Code, and my License is in full force and effect.
License # ! Lia Class Exp. Date t.
Date �"*' f"`'signature' of Contractor ....... .•. -
f OWNER -BUILDER DECLARATION I
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:
O I have and will maintain a certificate of consent toself-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.
( ) 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. M:t workers' compensation insurance carrier & -policy no. are:
Carrier 67 NE AND Policy No. it�i�li.S lti
(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 comply with those provisions.
Date:') Applicant
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 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-) 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),
-Date-
BUILDING
r'r
r�
' PERMIT007
BUILDING��i
GP�yE,ytRM�yIT .
DATE / ,.VALUATION $2.5 ,1180.0ei'iY -LOT .. 99 TRACT 4?r Y ai
% <
JOB'SITE 80-688' X111 S.A.V0..11fA
APN 772$ 460-01.15,
ADDRESS .
OWNER
CONTRACTOR / DESIGNER / EN INEER
6�`.�-KGOW A.1 01A1 13,113'C
:SVUt0101VI+F' Cc'2. Ti l �01R ; F.0N
'77„56 C.`GUWI YC7.,UB.0WW,” 181 137
E r., S_C;C)�7 : ; �"i,i i xtt. r 7t:;i X50
USE OF PERMIT
WIF110:1.1 : Rfilv_T Y' Db'Eri�.i.,;i.'Ma
f
�:1fet
w1�� • LaJ•f' Y..J i 1.I• .sar. e`•.na;.a�y��
� u `. «oor..:... _ ..•..y - ,
P004 SROL OR DRWZVF fd"C'1�?PRIZ$A.t'•H,
f .
CUSTOM CfV114iSTRUC:A`iON
RyC];iP��I¢P�i/�'fj�'Iry4�:ap+�(i 293•.00. Sir
�Y
•J.C'll4t'L�,JAS,Yl'AL'il[ V1.�.4 651. V 4-- -
1j1MA11r YEE 0 WAMAR Y
Cv'ri7;cIR.UE:'>:JONFE}?:
S'i<•kN S,HIECmC:1>NE1. -8,3,�f113
MIC1011TICIALL FRE 1 -0 1 -000, -4 21
ELdCYRICAL PEE 1 G1 -C)000 41210-000
MUMBINO FEE 101 �,000.4190000
STROW;.0 MO`f3O2d =>?Fp - R&VID 101-0000=241-000
QR41WIA1r FEE
rad ,f%0PFR IMPASCT 11.07, �7,�i S, Kt' ,
aid: fil �iT • ':cirT °I"!i'�J�'�`t!�28 i�
1ss '�,Asti� �:�IE It
,1 .9 .27
1�
Pra�PAI :01 VIE, S
J LJJ.CY d 1�If � +1I�' 'VEi S DIA' NOW
,Vr/�/��
RECEIPT
DAT -
2
ATE FI
INS
CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings
Slab Grade VReturn
Ducts AA
Air
SteelCombustion
Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
InsulationVents
Fireplace P.L. f L
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
_
Final
POOLS - SPAS
BLOCKWALL APPR V
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING PP OVAL
Gas Test
Electric Final
Waste Lines 4 AHeater
Water Piping _
Final
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
Appliances
Final
COMMENTS:
i
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
A.
Main Service
Sub Panels
Exterior Receptacles
G.F.I.12
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)