0307-158 (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 j ��' 1, Signature of Contractor • •' '�
f 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). r '
( ) 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 liy Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will mairitain.workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is �Issuec�. My w rkers''compensation insurance carr er &,. olicy, no. are:
Carrier .. a'<U'1 , ftrfflor Policy No. �f li v,d•!'d
,(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':"I 1-1- ,Applicant 1 ;r
Warning: Failure to secure W&kersyCompensation coverage is'unl'awful 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, indemnity
& 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 eriter upon
the above-mentioned property for inspection purposes.
Si gpature (Owner/Agent) . w'k *4 -r. Date 4'
V BUILDING PERMIT PERMIT#
shit "1••�.3i�
DATEV/1lUATION. $224a2n,60 LOT,:- 10$ TRACT 2, e —2- .
JOB SITE
ADDRESS �Q^7?� ' 1.
APN 7112,470-W3
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S.ED ONA, % IS, WC
fr.'UPIc7OR-AIV:0K
77-564 4 C4iixt?"! Y C',.UB D RTVE.2FM.fE 13.11
77-645 000. .MY .Mm v iiw. sw':� Y tso
PA, Uif DMAT (IA 9221
CA 92260
i '%777 412, C --.1 1137
USE OF PERMIT
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CHRY, CK FEE VUP1'O1a tfL•TIFLI,,'f1' IS'Stl1 4- LT,, OVSAME ME FLfX4 TYPE
C*M- 0M, d'Or iSTR CT10K Z640,90 OF'
t�C T L1ii9s�A`ilii .546.00 Sr
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MMATMI COST OF 00105TEXICZON
AUDANARY
(' VASTRUCTION FEZ i 01 _01007-111 18-000 spwoo
PL.VA CHECK Kv. l a'. 9214.34
MRC:141S HCAL FEE. 101-000-421 -000 $109A10
M 11:. CAL ME $136.26
.
j ,9.iM[ 11a :K • 101-0 00w E 9"-000 3'i 23
&TINVidO MO%ft314 FEN iyaJ;rM '101-:000-241 •rUCf1 322,43
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ART i t PUBLIC,FLACU9 - :tr XI r 770.0 , 0 -•445 mOQO860,' ',i
StxltNa,�J'; :A3,: )3d.1 4fTTt;TICy,1�t MM..R�v; CHECK '
$4,73.•130
RECEIPT
DATE
BY <r ✓ INAL PE OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 Footings
—/5— _
Ducts
Slab Grade
Return Air ✓
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
Insulation
F.A.U.
Compressor .00
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
POOLS -SPAS
BLOCKWALL
_
APPROVALS
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
—/_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
A
Pool Cover
Sewer Connection—Encapsulation
Gas Piping
F
Gas Test
Appliances
Final
COMMENTS: `
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service 40_
Sub Panels
Exterior Receptacles
CE V
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)