9907-088 (SFD)r..� LICENSED CONTRACTOR.DECLARATION
IV).. I hereby "affirm under penalty of perjury that I am licensed under provisions of
I- Chapter. 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
C '=) ch License # Lic. Class Exp. Date <
�
t►' 407.4 8 , Q7/31/19:
C:) Z r.:_WDate _ Signature of Contras of�
r- O' o
J �p OWNER -BUILDER DECLARATION -
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's_
ULicense Law for the following, reason: a.
Z ( ) 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).
t (.) I,,as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. X70.44, Business & Professionals
Code).
4 cY) • O -1 am exempt under Section B&P.C.,for this reason
+- LO
N Date Signature of Owner
Orn
Vi Q WORKER'S COMPENSATION DECLARATION
p .;cc 1 hereby affirm 1 under penalty of perjury one of the following declarations:
O O 1 have and:Will maintain a certificate of consent to self -insure for workers'
X LIJ ILL.. 'compensation, as provided for by Section,3700'of the Labor Code; for.the
0 J Q performance, of the work for which this permit is issued. ;
m' Q C) ( . I'have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
IlLOH permit is issued. My workers' compensation Insurance carrier &policy no. are:
Z Carrier C(}f. Policy No. CF
} : TXL
Q (This section need not be completed if'the permit valuation is for $.100..00 or less).
'.. -JO. I certify that in the performance'of the work for•which this pe_�rmit is issued,
? I shall not employ any person in any manner so ;as„ ik-ecome�subject to the
IF
workers' compensation laws of California, and,ag a that if l should become
• subject to the wrkers' compensation provisions of Section :3700 of the Labor
C�d s all fo hwith comply with'those provisions.
�te. / cJ Applicarit 7..
Warning: Failure to secure Workers' C�Comp sation coverage is, unlawfu and
shall subject an employer to'criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for.in Section 3706 .
of the Labor Code, interest nd,attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit ,subject to the conditions and restrictions` set forth on. his
application.
1. Each person upon whose behalf this application is.made & each person at
whose request and for whose benefit work is performed under or pursuant to.
any permit issued as a result of this applicaton agrees to, & shall, indemnify.
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if.$.
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_ a uuthorize.re; resentatives of this City toe ter upon
the above-mentioned propertyy forns
pection,purposes.
Signature (Owner/Agent) '� Date G .
V f •�
BUILDING PERMIT PERMIT#
�t17-�D�11
DATE VALUATION LOT TRACT
Am -17, 23154
JOB SITIt
ADDRESS VIA VEN.rA iA
APN. 646p-322-002
J7$_",5
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'£'QD,ESE wr1 EVciLai, NIFwrIa',
CGIN!"f,.OWC7`.1014
TO O 8OX 11.16
79.295 RANCHO LA QUfNTA IA.
LA QUIN.PA CA 02253
ISA QU.I%�4'A CA 922S3
i.
(10 771-1941 (4L## 299
USE OF PERMIT i• /� ( a
iCal.h ,FAMiL. Y L)L'1-9,hL► 40
SPD - L€)T 57- PI,i+14 V.1C,R -.IMT- nu1;s Nuf 1: D -E BLS -CK WALL
OR POOL. ,'75%PLAN i U1<.i:K F K MA:1`• ON FOR MJL17'lKE
' I. f�l`i.�f+✓l rai lQri;`Y. ._ 5W.00 V
.. U:!U.83e11 1EM l.•<N3 OF r..:VNe7,.[•di.. 31 F.tiY.i`1
iZDCvpsi�Yt'>.�eV
PERMIT VE rij SUMMMW
4UNS"rRUC'i'FO1v Y1+..1 101-0*418-000 I,UO
PLAN C-MCK FER, $177M
MECHANICAL F03"
8LrCTR1CAL F01' ' 01-000-420-000
P'LUMFk1NQ4 FEEL. 10.1 000419_000 W%M
T1?(�?�7rfCil0li:f"C4 �:2��5 ;nl,(►f)Q ?4j-ff1}tT ' ;,.` _; �stc,'
.
..GRAD.INC•FF .. ).flt�i )a. 23•UCO � .ad
ill i$ ►1Rt7G1 Ttd! .1�1i% 225-1i40-441342 S-5,792,05
ART .1N KIBLIC PLACIRS - C IS •70.1-f.;U( 455-000 ' 31 tTi AO
fui.5.,z780
LESS PR., .PAID FE4.6S'
$0.00
i
4 Ww 1.01•„AJL PFRMTf FEES losNOW
$ 5,378,63
RECEIPT ”' "'
.DATE v
BY 1
DATE FINALED
INSPECTOR '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
G
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- C(j -
Exhaust Fans
F.A.U.
' al
O.K. to Wrap ZQ
Framing
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 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
Pool Cover
Sewer Connection
t
Encapsulation
Gas Piping
Gas Test
6
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) — dV IA--