9907-081 (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.e ect.
License # Lic. Class Exp. Date
1.Date' ' Signature of Contractor -
t
OWN ER-BUI LDERaDEGUARATION
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.
( 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 Policy No.
r -PAXpr r i sr. l _ ` �w
(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 thatVf I should become
subject to 'he w�° rkers' compensation provisions of Section 3700 of the Labor .
Coder) sCiall fofthwith comply with th�os. se provisions
Date:,}%fir=`9�� Applicant f s
Warning: Failure to secure Workers'-6om'pe sation 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 C,ty,and State laws relating to the building
construction, and hereby authorirepresentatives of this City to enter upon
the above-mentioned proper y(or inspection purpos s. �%� f
Signature (Owner/Agent) G� Date /
r�
BUILDING PERMIT PERMIT#
'SRU%OF8I.
DATE_ `(C VALUATION LOT TRACT
30
JOB Srr�
ADDRESS}..
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TYt ��: C g1C�fi t� r Yi r ra��4sr� rr
1.1.• ..•1.71,8.,1 .t �l • Y 1..'1,J.,0i. }�'.,lV 4
< l 1 1.ani= : +/ YAt i•+ > le'•fron'I`I
•.d'L..t.l if♦ Ow'•.✓S•i'+A.l V.� 1.7tJ
ws. In,
a'i� 6v.;�s i z
y . ♦ .. r.
;9-2c9 ii.t'UIvi, HO LA QUINM .C��t�.
LA. t; W..NV GA 32253
LA QUINIA CA 97253
(76 0117 7 1 4 94 1 C:RIN 2996
USE OF PERMIT
aN+31,,.UANi.i;, V DW 1 LL IN1 G
gas D -LOT 30 PLAN 411- Pl:iW00jIS iv tT I%7C i:UDE BLOCK WALL
+:3Ft,1'i"�;L. 'lS°lo �i,..a�.ht +�.!°i�3:ic irL4� it�13i7t� 1'IB"J±�i .t�'C'iti NLt1t.f:'Tf Ea1.E
s':Ual'CriliCr�fJ� I'S°.Zl!"TIG�t 566.00 Sl
.('i' R-CM),A110 tttlM sr
i3AtiJ1CII'1CAfti�S71t.1' 6SS:Utf SF
Yr.I.N.I a#tl1 A! U' d.Y D'r.f l', a�Od l.ijid[lNi. II�l
.CI4A ".Val A 0
C4? VS'rRUCTI,ON:E'.I 101-00011I N-000 S1.E�>a1�.S9
PY-1 AN r,: rFIR 10.x -01W-419-418
r1LW1i"1UC L FEE 101-006-1128-5-00 .:i J0.91.
I"LWABINO FEE $16125
OT 1O`N FF13 - RE IP 101-000-24.1-(t(1ti g2 138
GRADINC .FEE ' I 101-fM•4223-000 $20AN)
WFit.NSTRUC`i'i7R7;.14W1 2.25.000-44-1-342. S31,786.41
A.R.T .iN PUBLIC 1"IA.fit,'E8 « kf 41'1: iti!-ii0L1-23S-I}tlCi $284AS
S03-1r,)TA!, C.C.tM-'f RU(`; i ON .t1ND CH C, CX
i.ESS RU-P1'III),PEES
$0.00
j
L.. s
'1170°J'AL PERhl117 F~EV'S 0UCNOW
$6,71,409
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade
Return Air
Steel.
Combustion Air
Roof Deck
O.K. to Wrap
22_
Exhaust Fans
F.A.U.
c
Framing
X9-
Compressor
Insulation
—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
G�
Drywall - Int. Lath
O • Z —
Final
�
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
Appliances
Final
Final p
Utility Notice (Gas) _ OU
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 2 _ GV
Utility Notice (Perm)
COMMENTS: