0201-036 (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 ,ff�; Exp!Date
Date, e�/ te� z 1 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.
1 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:
Carrier SPLATE FL314D Policy No. 4S3Q►tfS��1
(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 soeas to become subject to the
workers' compensation laws of California, andVagree� that if I st ould become
subject to thefworkers' compensation/provisions of Section,r3700 of the Labor
a 11
Code,,.lsh�alljforthwith comply with?those pr'o'visions /
Date. f'I 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 5'.
any pemit issued as a result of this applicaton agrees to, & shall, indemnify A
& 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 issuanceof 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 autF 6(6 representatives of this City to enter upon
the above-mentioned prope rty°fo inspe`cction/purposes'.��
Signature (Owner/Agent)' Nct V A- -iWr Date 7 . �''-t`� /
BUILDING PERMIT PERMIT#
E1f201_0.56
DATE _ VALUATION q�p �7y�y +� P LOT { g TRACT
�r�,.d ., � ,, `/ ^`3 4-"di"i1:/4'4x:£9wGl.)! 1.,Ya .dr✓��Sd" /.
JOB SITE
ADDRESS M-320 VM UCM
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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1425 .C. M_ 41 ii?MSY.F Y IJRPM,
LAQlM r% CA 9212s3 ;'
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tti�pp ��gg81034 LA 990
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USE OF PERMIT
swcax F.iA 'SLY.m i l..;t o
&I'D = I.OT 65 PLAN afill.f C-1. i'�''1 MAT DOES NOT INC;f..'LYDE J3'LOC:K
WALLA i'004 OR 1:9R1Mi?'AYAi'ii°ROACH ;
TRACT tlONMUC. ION 4,024,0 O1'
3'ORCHllz,a M 402,80 SP
pmalf-1' ri` ' 119UMMQeR'§a''
CON Tr R U C T I ON YTI 101.000.418.000 $1,.143,50
PLAN irf1Kf. K FLPE 101-000-439-318 $573-65
MEC H,9fflC1` L FEE 101.000.421.000 $137.00,
C,+:UCTRUC "1'ELi' 101-000,-420-000 $2 .92
PLUI ?THOFLS? 101-000.419.000 $249+25
(YrION PKE: - RESID �� 1(01-tiE00-241-�Oy��Y)0
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0 1 -000-4,23-6/00
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A.1'1'I'•N MUC PLACIM - RNME Z 0.00Q_"5_1' 00 $108.65
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C17Y®FLAQUINTA
FINANCEDEPT
RECEIPT
DATE n a
BYDATE
FINALED
INSP OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
U
Underground Ducts
Forms & Footings
Ducts
Slab Grade
i
Return Air
Steel
Combustion Air
Roof Deck
i
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 7j- (S
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
Water Piping
S `�/ C _
_
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
COMMENTS:
1-60jTS (0 `� _G 2 �- C
Final z
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) .
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INSULATION. CE° TIFICATE.
This is to certify that insulation'has been installed in conformance with'the current energy- ;
'
,
regulation, California Administrative Code, Title 24, State of California,. in the building locatecIA: . -..
50-320 VIA SERENIDAD , LOT 65, LA QUINTA, CALIFORNIA
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CEILINGS:
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TYPE:BATTS 7 MANUFACTURER: CERTAINTEED THICKNESS:'R-38 {
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TYPE: BATTS MANUFACTURER: CERTAINTEEDTHICKNESS: R-21 ,
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GENE L CON CT R LICENSE #
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TITLE:�lI��U�l(1�U(.
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P ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
rzr TITLE: ADMINISTRATIVE ASSISTANT DATE --1,1 /,1- 3,/2,00..3
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