0211-032 (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
41.30103
Date Signature of Contractor ,..0--�-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) -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).
( ) 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.
( /) 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 - LINKRiTMUTUAL-K Policy No. WA262=4 23012TE
(This section need not be completed if the permit valuation is for $100.00 or less).
( .) I certify that in the performarice 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, 6 s, all f rs :
thwith comply.with thoprovisions ..
Date:fi &e,c .' 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 Js 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.
Signature (Owner/Agent)' ” °"`'""' Date,,/,.,.
�-
BUILDING PERMIT PERMT#
DATE VALUATION LOT q y y ', �.•,•� TRACT t�
4—Ura4
JOB SITE
ADDRESS V VA6iA7Ad0lj
APN
^e1'id.q .5
OWNER
CONTRACTOR /DESIGNER / EN INEER
`.(°Ou, BAO j L:t": AV ' .
`?: ( i, i.• Yv`f'kll #3, .1N
'7 3.121 51�,v_7 wival-Rip 0 100)
i A114msuvxr CA. Q21260
PALMDE;,�ftRIC : C-Ak 922.60
(760)674-9699 caul 4832
USE OF PERMIT
5e'"rJ < 1,OT,1 ; ?CJI.d'AfJ3 Pii..R.M'I T OMS WOT dN0X1DE BLr_)CK
WALLA POOLSft OR 09N. 9WAYAPPROACH
6;i.YOTONIC COra'S5'iKUCTION 1269:0015F
rMORC1•0PATIO 336.00 Sit
GAA!lGIUC.AARPOR`C 811,00 5?
R91.CL7`: TED Se'LiMOY TFr1iJ.1I:Y1MPJC.!'iSOap
2 fe:7f7✓.&',:izo
CO1t OTRUC` 1,0114 FEES 101.000-418.000 $1,251,50
PLAN C�=aK'Mr. ls.01, 0G-439-3105
,MEMIANICAL YZE 101„000.421.000 �11�I,50
ELECIT, i'•.IC.Pi„L FEE 101-000-120-000
PLUM 1: eFRIE., 101,000-414-000
;3'1RONL1MOTION i?TZf • 1i VID 1.01-000-241-000 1i'��:IFt1
ORADi14O FF%, 11011000_4238000
DEV-Ir3:;O0'E3t'tWACT PREb�?y�3fi�:(JQ
ART R4 PUBLIC PLUM -1 --X, Or 210-000r.445-000 $11V.0
_ A ii. -'- � YTAiH , 7VAO J<.�d.S.!Y ANMD P:1..f�J14 �� 1.4'�O.q;I1W
$5,414,6 t
K! �ai.1:"no n- .`.IrFEX,8 _7 NOW
CITY.OF j�AQUINTA t
FINANCE DEPT'
j
$5,414 t�
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROW
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
D 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3
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
I
Gas Piping
PLUMBING APP OVALS
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
Sewer Connection
��p �3
Pcol Cover
Encapsulation
Gas Piping
Gas Test
_�(� •0 3 S
Appliances
Final
Final
I ELECTRICAL APPROVALS I
Power Pole
iround Conduit
Low Voltage'
Fixtures
Main Service
Sub Panels
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 4103
COMMENTS:
T�A`uj�)
it, 6X13