0307-157 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
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UJ Professionals Code, and my License is in full force and effect. 14
O C) License # Lic. Class Exp. Date
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Z r,, /Date"r, Signature of Contractort----- t,
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co OWNER -BUILDER DECLARATION
W UJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Cn License Law for the following reason:
Z ( ) 1, 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). , 1 .1
( ) 1, as owner of the pr6perty, am exclusively contracting with licensed
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contractors to c6nstruche project (Sec. 7044, Business& Professionals
Code).
CO O I am exempt under Section B&P.C. for this reason
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C\1 Date _Signature of Owner
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< WORKER'S COMPENSATION DECLARATION
0 Z> Z I'hereby affirm under penaltyofperjury one of the following declarations:
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F -w 0 1 have and will maintain'a certificate of consent to self -insure for workers'
X LU ti compensation, as' provid4d for by Section 3700 of the Labor Code, forthe
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0100 -J performance of the work dr which this permit.is issued.
< ( ) I have'and will mainitaiii'w'orkers' compensation insurance, as required by
O ()0) Section 3700 of the Labor Code, for the performance of the work for which this.
cc LO permit is issued. My workers' compensation insurance carrier & policy no. are:
Itt. 11L Policy No.
Z Carrier el".11111.1fle k THD
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< (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
161 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 Cos ' t of compensation, damages as provided for in Section 3706
of the Labor CodelInterest 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 uch
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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 upon
the above-mentioned property for inspection purposes.
e
41,
Sionature (Owner/Acient). Date -I
PERMIT#
'BUILDINGPERMIT
DATE YAtUIATION LOT TRACT
1 02 29A044
V 5
JOB SITE
ADDRESS .60-717WA SANFUMA,
APN
OWNER
CONTRACTOR/DESIGNER/EN I(NEER
9 U14 R 0 ff- 00i: 0 R A-,, 10 11
4g 9ti0 -A BON 5T,0330-13
49�'959
CA. .19720411
iii D10 CA 922,01
USE OF PERMIT
affil"ULL, FAIAL Y rf VF11 IIIN0
P001,01M. OR DRIVEWAYAPFR16kCt1
CUSfOM- CONSTRUCTION 2019.0 OP
400t� 116 Sp
CARAGEWARPORT 6!"
ESTMA=', 1) CO;V:V (W CON RoIRTICUONill)lxo
P M�AaT M SUMMARY
COYIPTRUCTION T-21111 103.000- i3 "00. 2111120150.
PI.AX CHF.C.r. FFY' :101-000-439-318
'MECHANICAL Fr1r, 101 000-42 1-000 stop.00
PLUMN'41140 FEE 101-000.419-000
GRAD -Nd YE IM -000433-000 SO.%
114fiPAC`rA!F1'
NPUBLIC PLACE3 - RRAUX
SM, -TOTAL C0X'.1rnR1X n, W AND MAN* 11-N-,,7,E(-vK-
$4,W3,36
PRE-PAXIF M119,
ft,00
WD
T(1MPFrdA.kT IM VE NOW
115,93 Z6
RECEIPT i
DATE,/,BY
1
!TIN SPECTOR
.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
19
Forms & Footings
Slab GradeReturn
Ducts
Air'
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
✓
F.A.U.
Framing
Compressor
Insulation
-
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
BLOCKWALL APPRO ALV
POOLS - SPAS
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
Pool Cover
Sewer Connection
< j
Encapsulation
Gas Piping
" -µ
Gas Test
Appliances
Final,
Final
Utility Notice (Gas)
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:
-