0211-031 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 700,0) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License #may �lLic. Class , Exp. Date
D }�1
tl�l
Date Signature of Contracto,pay
r ��;L;�''���-
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).
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.
(�) 1 have and will maintain workers' compensation insurance, as required by.
Section: 37,7 6f the Labor Code, for the performance of the work for which this
permit is issued. My workers' 'compensation insurance carrier & policy no. are:.
Carrier MUM? MUTUAL F Policy No. WAVON04W3611�r
(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,'1 s all forthwith comply with those.provis ons.
9ate:7 Applicant 1 Jr�
Warning: Failure to secure Workers' Com nsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to'the cost of compensation, damages as provided for in Sectionr3706
of the Labor Code, interest and attorney's fees. 4. {
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions. and restrictions. set forth on hiss;.
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,'indemnify `
& hold harmless the City of La Quinta, its officers, agents and employees.
2..Any permit issued as a result of this application becomes null and void if
work is not commenced within 180' days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
y p�� Date ,
'Signature (Owner/Agent);
PERMT#
BUILDING PERMIT
ox
DATE VALUATION LOT TRACT
30357
JOB SITEG j
ADDRESSZ� '�: Al _tb r .J
'${"
+ e
APN
' '7-50-01 �'-
!CONTRACTOR/DESIGNER/EN
OWNER
(NEER
TOILR.06L MIS M'.
%3.121 ppm WkWxo loo
7342,1.. FPM WAIUR QPiW
(760)674-9699 r...11b 3832
USE OF PERMIT
i Cq,C3t� 1 C3� c ' t tri � I"OOL SPA OR I L �iTFiFi�►sY ,r'.'.}'J�C�,1�,5 P.1'
CUS` OM C0,14U.C.RUCT:!'.1Or1 36H1€9 2F
R.CH10m,10 MR100 F
Ui A'MD COST OF C:U?:C'�'2r".'ATt UCTION
1317-41195.%)
CONS 1'RUCTION Y:L)s'; 1011,000415,000 51,427.00
PLAN le H�'ilr#, PEP, 101-00�' 39-319 $1,ubl,65
ME0HAI IICa",A L &moi.. 1011 �00f1-411.000 ei %op
I? i 03 -0(x -4-4 -ow
PLUMBWO FER
ST:RUIND:P OT1ON FRB --'92311 D 101 -241-..!000 S3.;A2
ii lti iii, hYt. 101,.1)(00423.000 Saw
AT3 ► im PUBLIC P11AC F1;4 -AEA. It!),NCE 0.445. 00 331046
p �:� .WYTALC :FRU<�YTOX KIX)PLM �� :.
U-1,13 PIRSM TO I�'xs. d� y
std, 00
04 •CNIFHy.II.Y. ,E` Dt NY.C•cA
CITYO► LAQUINTA
FINANCE DEPT � y+
. y'?. "
RECEIPT
DATE b'^
BY
DATE FINALED
INSPECTOR
r•
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
s
Ducts
Slab Grade
Return Air
Steel
-
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
jj
F.A.U.
Framing 1,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
p
Drywall - Int. Lath
/
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 APP OVALS
_
Gas Test
Electric Final
Waste Lines
71-
Heater Final
Water Piping
-
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
f
Encapsulation
Gas Piping
Gas Test
0 S S7
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) o �j
COMMENTS:
/E�NTt�S: �^
M�\ V � � N v1 �v� 46 L A,