0101-330 (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
031014(
Date ; " Signature of Contractor.
OWNER -BUILDER. DECLARATION
t
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 Coda).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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 worker's'
compensation, as provided for.by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have and will maintairi 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. Policy No.
(X)LX)R'H EMU 347011401
(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.-Califomia•; and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shalltforthw th comply with those provisions. r;
Date: _J: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fnes: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 peYso'nfat'�,�'j
whose request and for whose benefit work is performed under or pursua%.to,
any permit issued as a result of this applicaton agrees'to, & shaldin�@mnlfyl-
L
& hold harmless the City of La Quinta, its officers, agents and employees.
2. -Any permit issued as a result of this application becom) �ul�ar d,v�oid 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 enter upon
the above-mentioned property for inspection purposes. t {y
• Signature (Owner/Agent) t < Date '
BUILDING PERMIT PERMTk
DATE VALUATION LOT J410_1e TRACT
JOB SITE
APN
ADDRESS �q` ��pn �e y y t
6, d8—WO R.xA JX *EI'17P.dWCE�A
/� g +Ry y x`e3 Tp
604-211-9 39
OWNER
�.
CONTRACTOR / DESIGNER / EN (NEER
.
D^'fit iOPMT-1iT, 03
RP. Ci"�:MUR l�C�:EY��f�.��Tt �1'�I.CiN�r�At�', COJ
? X57':• fl f 1'3 1 F 13 ;�
;5S-487
LAQt1WA 9=1 3
U&QUZlTA CIA 9225
7C 0� b�i4^ i "r Ck1i 5487'
USE OF PERMIT'
s SES . 1. qT 12.P'C YN 3h . PEIRMT .PQFS NOT l'NC,, Uf1ft BLOCK
WAiJ.,OGtiLOPA ORAPPROMMI DlatVi'1aiAY,
TRACT CO.K8TRUCTIUN., a,228.0fo '9F
u3.09 Sir
-000-41 F-000 5954.50
PLA1114 CHECK Fire
�ppq:,W_3101�ICw'.tY}tLFEF )bpl��^i►tpry�����
Rqfn1ly�1(3��04
.t�ILIelrt;:1111�.?L«.0 L 1171:1 101 ^V�J'O/ —20-000
P'LUiMB ooFiFIE 101-000-4,39.000 Sl°74;
711'.0'74&1 MOTfON 'ano, • lizeaw 3, o 1-666-241 ^;lop $10.93
.K
tilt f b P 101-0-00-429-000
d
Se 41'r -IM. COME TRU67109A.t ,)��.iX.fi.Kc°:���;t::D
��.�s
a :q0,00
PVTO
A
�i
py�
J.'bd'A RE+.HIM.i FJ!sJ':DS- .i:WSA NOW
94,131 ,02
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
-^ i
�L
I
QA)
P.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs ,
Forms & Footings 22 IP
Slab Grade 7
Steel _
Roof Deck ?j
O.K. to Wrap ZZ_
Framing �� /�/ `
Insulation ' /j�/ o j A
Fireplace P.L. r
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
I
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Z(j�
Final
Final
4925
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
'
COMMENTS:
Final j . yz _ >
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.171
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �`