9907-085 (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
674074 0
p % _ i5 N� ( Signature of Contracto"r
111 4444'
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury hat 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 & Prof essionals:,``.`
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
Ihereby 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 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 Policy No. ,
,.,(This section need not be completed if the'permit valuation is for $100.00 or less):
( ) (.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 tothevyorkers' compensation provisions of -Section 3700 of the Labor
CodeJ shall folthwith comply with those,provPsions.
Date ��? • ✓ Applicant'
Warning: Failure to secure Workers�Compensation coverage is unlawful nd
shall subject an employer to criminal (penalties and -civil fines up to $100,041 in
addition to the cost of compensation, d'a'mages -a p vided 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.
'fora 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 prop rte y for inspection purposes: %
S4gnature (Owner/A{gent)_dyr--� �' / Dat0r��•�
BUILDING PERMITPERMIT # '
DATE VALUATIONi i %3 �6�7 so LOT S TRACT 251'54
JOB SITL
ADDRESS 79-935'6 IA VEEMt' A
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PO .WX 1716
79-295 WJCHO ILA QUINT A. DR.
I A (t(.)IM'A CA 9,225°1
LA, c�1,7ik'.t�d'I.A CA U215�
{,7W)771,1941
USE OF PERMIT -
SINGLE FAMED �iIAWh;LY..•ING
SFE) . L(YP 34 :A'LA'I` V13-17IwCtwT LC3'ES 140T INCUDE BLOCK WALL
CPR P X91 , �
:y
cuNT comv. zaaN 074.00 SAI
dARA0$1Cli}{j 0,RT- 617.00 $J
RSr�7c'.t.tYAB'6-t9 Ar �eM.')D `V94�M't�'� 9f�'d Rye Ll�tl�.N.I1��
L•f.�Y�k���.¢Qtt�7
M SUMMARY
C0143TRUC"41ONFEY" 1.01-000-41840) $89
r�tI-V r,K rt,� 1-l) `I-4 -alb 73 •�`
Ma'33/ti11G�'>�,
E.LEC'11ft1CAL $133.4
�Lti�?ZlNcr h( 101-000-419-000
i7.y7�
• ` :�,i�1{m� t�+��'�"�f; •l�i F03 - t^00p) 101."0W-24!-000 S17.17
GIR,. -ZING .FrE 101-000-423-000 -423-000 S20M
22 -f3i' 1l 44 x-342
ART IN PtMLIC PLACES - RESl.L> 701-000-255-000 S1,84.14
wa-71n.Ao, Gws.!"�.t7C":rJON1 AND P.%,AN t`,HEM
6,114.E
LESS .PRE -," FEES
$0.00.
r .F TH? �y Ettf t.1. i
`$."UCAL PERMIT $'i x!;13. S ID3J;1!i', NOW
$6,114.34
RECEIPT
DATE
BY `
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
.BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
L
Underground Ducts
Forms & Footings
Ducts
Slab Grade
2
Return Air
Steel
Combustion Air
Roof Deckq
Exhaust Fans
O.K to Wrap
o- (
F.A.U.
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
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 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
Encapsulation
Gas Piping
Gas Test
• VCJ
Appliances
Final
Final
Utility Notice (Gas) ;7 Cej
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 _ p
Utility Notice (Perm) — c GCS
COMMENTS:
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