0012-120 (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
S/� 034'd 1 /2
Date rf 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.
f 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 AMERICAN fiLUR-Il_ Policy No. �,f���f;dtiib319�{1a
(This section need not be completed if the permit valuation is for $100.00 or less).
( )1,1 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 w4ers' compensation provisionq of -Section 3700 of the Labor
Code, I shgil ortVwith comply with those provislons�/
Date: 1 i 1� Applicant
Warning: Failure to secure Workers' Comp n tion 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. { �•k
4 j p
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 forinspection purposes.
Signature (Owner/Agent)' Date
BUILDING PERMIT PERMIT#
DATEfi/h VALUATION LOTS' TRACT
JOB SITE
ADDRESS 47-W .IA 37RM"S17
APN
q54q -0 �ty�a
41"4.. ,«�Lj;{�'..f+`�G9.
OWNER
CONTRACTOR / DESIGNER / ENGINEER i
CAN/DAY ARE cowitH"Y
C.f A)Al Y & (1030PA W Y
17480Z 17111 UP # 105
17480 E, 1711-11S ', q,106
CA 92780
1.'t1`,,YXON ' CA 92780
(11 X4)508 -U40 CW41,, 44.85
USE OF PERMIT
$ihIC.E.4"_ FAMM d »VV.L 11NO
.LA)d 777, PLAA 10A'. SPD - iii+ hIlT GOES iJ n'.)VICR,;.Di19 BLOCK WA:f IX
P001t Olt. DRIVEWAY APPROACH.
T94CT CONSTRUCTION SP
POxCHIP.ATIO 37&00 Sig
OAR.AO1V« ARPORT (3F) %604.,40
r
ESMU:�:I:W COST OF CO11'ISTRUalION
145.14-6A0
PF.�1 FEE NITMiAIARY
CON-01TRUCTION UCTION VE 1101.000418.000
PLAN GI1t;tIK VZE 101400-439-318 X663.93
MR DEPOSIT 1.131.000.439.318 42$0.010.
�yy3�CPcx�r�tf�iC.dallp�'i�yCIC . 10y1 �(*�,/O�p0-421-000 s�;G 5t1
PX.i:iMBIN'Ci :IGIFI 10'1-000-1119-000
STR.ONA3 MOTION Feft• REMID 110)1.00.0.241'000
SSR.AE'SlNG FEE 101 •000.4.23-•0011
DEVR C 1%R 1.M.P,AC:T `FEES
31Y-43,-TtWAL COWErrFUC"`.E10M.AI"#`.!y kPd.,M Cf) ECIC
$3,71121A
LM93 PR.1_4;-PAU) FFXZ
4250.00
ID T (7I.'AL PFNAiT FEES :19 7' P'd: W
Sth,527,:24
JAN 0 2001
---MY '
7 f
RECEIPT
DATE e
By -'r; /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/
Underground Ducts
Forms & Footings
/
Ducts
Slab Grade
�.
Return Air
Steel
ol
Combustion Air
Roof Deck_
O.K. to Wrap
FramingQ
Insulation
Fireplace P.L.
`p� _
G Z�j/Q� �j�
To1 -
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS
BLOCKWALL
A PROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
Sewer Connection
�� Lf/" "`
(((
Pool Cover
Encapsulation
Gas Piping
Gas Test
. !/ el
Appliances
Final
COMMENTS:
Final
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)