0211-060 (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
7776,9Y . B 4/30103
bate 1111,910 L' Signature of Contractof a
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)...
( ) .1, as owner, of the property, am exclusively contracting with licensed
contractors to construct 'ttie 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 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. My workers' compensation insurance carrier & policy no. are:
Carrier ,.1�Y}31R'"� 11ZI'i'�J.1.2• Policy No. sa<+a).22�d9'93k1:1�I'L
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 s all forthwith comply with those;provisioys.
Date:is✓�� • APPlicant^ l/., }'k G•lisa�a...--
r ,
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 i
for a permit subject to the conditions and restrictions set forth on 1,his
application.
1. Each person upon whose behalf this application -is made & each per."son 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, indemnifyt '
& hold harmless the City of La Quinta, its officers, agents and employees; 0
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 cancellatio
I certify that I have read this application and state that the above informationis
correct. I agree to comply with all City, and State laws relating to the buildi g
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspecti n purposes.
'gignature (Owner/AgentDate
- BUILDING PERMIT • PERM T# _ •4It
DATE VALUATION VALU� }y}� LOT TRACT
• � � t �.,.: f � / °� .��.*, , --="''---�-
JOB SITE T
ADDRESS C+ i7'JA .!�tcg.L€qV: �`
t 1
APN 'Y.tyM••,�.�-i,I. i
OWNER
CONTRACTOR / DESIGNER / EN (NEER
173 121 ykaw WAM90101 00 •
73-12,1 FIRM) WARRING 0100
RAW D % 9221640
P��Y�//:�.�,,;���5^^:r;kE.S99.F[�tyy�i: �;A���yy922,60ull
36 7
USE OF PERMIT
SFO ',JI P3itt?y tS'�1;'62` F�Qfk+ .TT D0P;S t3T114 E WC V L➢..5,
P001, SPA OR, DRIVEWAY APPROACH
�
1
CUOTOM C01MOTRUCTIOta 3,t74 Qfi• r+
z' �ORCi31PATIO 2:04.60 S?
SF
252
"m
(110NOTRUMON ME, 101«000-418^000 $1 J76,0
,
MECHktiNPO.e U F 9 101 %J15111100
ELZIC'I';1).C•AL, V0, $194.15
PLUMBINO F90 101AObO-419.000 ►3,7,^.
S71fiONCf M.DT1014 FEK • RFMID 101 060-2.41-000 77
f.rRA.O:11+3O RC:',K 101m000-423"000 $4:1100
09VENiLpEp.1MPACT YEE.
ART IN PUBLIC PLA , i #r, VO -000.445-000.
"101-000-4.39-3 18 $4500.00
8 •-`.Fi: f°# -At cbmc '�L`1'L'°l.'I.L�i1�i xi) Z�i...!�x a � .,.c.
•
AA
TOTAL 3. d' L S}J.Md7..4. J.' KEYS D E ,v.?�OW
��� ���"'' .+
6+i O
QUIN
IF A
INANCED
RECEIPT -
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION I
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
-
Combustion Air
Roof Deck
jf 3
Exhaust Fans
0. 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
57
Drywall - Int. Lath
.�•o
Final
Final
BLOCKWALL APPROVALS
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 �PPROlALS —
_ nn
Waste Lines �,Lr
Gas Test
Electric Final
Heater Final
Water Piping
s _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2 3 -
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
Final
I 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
COMMENTS:
1 A-& 6