0002-198 (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
t) 74674 ,% X17% A. 20(
Date 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).
( ) 1, 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.
( ) 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:
Carder Policy No.
.)b �g.(a 1•i.iAvl/ - +1'sii•Wl r�.�J�l
(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 3.700 of the Labor
Code, I sha11 fotthwith comply with those provisions. ^,✓� Ya
Date: r� 7�r� Applicant—
Warning:
pplicant 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 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
Signature (Owner/Agent)- Date 2 l�' r'1(.•',
BUILDING PERMIT PERM'#9fa)
DATEOm VALUATION $168.560.'20 LOT TRACT 251"
JOB SITE
.
ADDRESS 7 15 VI V FANITANT 9,
APN
646-322-011
OWNER
CONTRACTOR/DESIGNER/ENGINEER
5!'t1t`� f"C :"IST1:2.11C'Y,07
.Pi) BOX 17W
19-295 ;UNC I3O LA Q(J11, Tek .0R.
LA QUINi'iA CA 922,53'
IIA Qi INT.. -A CA 9W5,4
(7 01771�I�D41 CNA t
USE OF PERMIT
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SSD-.f„0T 46 PLAN VIE Pi_."i
Ott 1'CiOL. 75% PLAIN ChEC'X.*. F&,' ' R_FD0C.”. 'ION FOR .MU1AJP.LE ISSUANCE
OF SAAC PLAjT ( PE.
CUT31101MI CGSNSTRUIC'T►O.i4 Z038.00 SFS
C`fARAGEA.: tSRPOICC 50.0.0 Sv
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WC,' W, ACAL'VM i[011-:0, 0-42;143,00 r{t
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1'..7r11INCIAL ll'L".I'n 101-000"420_000
P1. INA61N. 0 FEE 101-000.419-000 61-16.00
S'1' f)NtY M. nT ( It>~ ;t'1� tt)1 d10i?-74. ;-M) X16 hfi
ORA10114Cr-EE 101-000421000 $20.00
0EV3J 0 .L -IR Mt. .ACT f : l; $1,907.w
ART (N PUBLIC PLACES-RE,S111) 10; -000 -ass -000 $171.40
i.iS� 1,':2T'•13.f�in.r; Lh,�j
a�?a�0
1'0'f'ALPER TM IT Fa+JES 19UKN0W
$3,49.013
RECEIPT
DATE
BY y
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs L�`
Forms & Footings l
Underground Ducts
Ducts
Slab Grade 'v — GC/ r' ;°
Return Air
Steel - -'
• Combustion Air
Roof Deck /
O.K. to Wrap _(9 ' OO -
Exhaust Fans
F.A.U.–
Framing GU .-
Compressor
Insulation
Vents
Fireplace P.L. -
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Final
Final
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 — - cel'
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:
c
a
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)