9812-215 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with•Sectlon 7000) of Division 3 of the'Business and
CSI W Professionals Code, and my License Is in full force and effect.
O =) M, License # Lic.`Class Ezp. Date
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o Z ��Date— Signature of Cract
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F- C) OWNER -BUILDER DECLARATION
W W I hereby affirm under penaltq of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
,Z ( ) I, as owner of the property, or my employees with wages as•iheir sole.
compensation, will do the work,.and the structure,is not intended or offered for
sale (Sec: 7044, Business & Professionals Code).
s ( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044,"Business & Professionals
Code).
co O I am exempt under Section B&P.C...for this reason
LO
0,
N Date Signature of Owner
Q WORKER'S COMPENSATION DECLARATION
CL
o 1 hereby ,affirm, under penalty of perjury one of the following declarations:
0 () I have and will maintain a certificate of consent to self -insure, for workers'
X w. � 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 U (.,..) 1 have and will maintain workers' compensation insurance, as required by
0 'UQ `Section 3700 of the Labor Code, for the performance of the work for which this
0):. F- permit is issued. My workers' compensation insurance carrier & policy no.. are:
Carrier Policy No.
0
„• J (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. �v ons o fSecti �t 3700 of the Labor
3 -Code, l sh o Fiwith comply W1 h�_th,'o a provlslons. a'//
VDate'",� J j Applicant!' ! -+
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 attorneys 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 t
± `& 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 grope for inspection pur oses.
i�
;.Signature (Owner/Ag n M f `' Date
• 'PERMIT#
'BUILDING PERMIT
DATE - VALUATION LOT 0 ' --^ "" TRACT 27899
�{
JOB SITE ADDRESS ^. 7 1 Y �E. i� pat'. .
APN 1 �- ayl -0i .,19
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i53+1 . "€3" S'€'.uz," ", STF. #200
t • ? SO. ".ia" EM'icRI aXM.-42u0
SAN .BER)'.4A ;;t4 j N0 C,"A 92408
SAN :13.£:1tNARD(NO CA. 92408
CB1.411 .2-1120
.- - "• f '
USE OF PERMIT
SINGLE FAMILY DWEILNG'
LOT 111,R:.Aty > k 5l`L7A612A JT D0FS N0T INCLUDE BLOCK WALL r"
(A POOL. PLA14 t;rWCK Fa, ISIAJA1NQ6 OF '
.`+dtV}9L PLAN '11TE,
7°x3AC CO I ST'laCtCTION 1, 50.00 S.1
-i" 1VkA,0f-VC ARr10R7T (16L00 Sr
• l
- iW 3 f $U'i'1f`ED COST OF
PERIMT FE We SUNIAMAY
CG S:i'RU1,;.10N ME 102-000-418-000 $6ii'a.SCi
K„n,N (I21Y `1-1—F R 1,01.{}00-4.39-.31$ti415.6
1tl1 Cl.f7sNiC tlt.• :FZ 101 000-••422-1100 $47.0
1 !•.i;C'fl 1 A1:..1 A01-000-420-000 I l3 2.47
PLUAlK VO 1FRE 101 -WO -419-000 S123,75
STIKONO)VTY Lf. N Fff, �- Y -f S- ID 1 I1 14)0-24! -QM. , $9..13
G1ZAD1?,',fd FIX .101-0004 23-000 $20.00
$3,4J37.49
L FSS F'.F._.1141 ID FEES
W,00
%,�- T'y0n P7� 13"F$ DU ;fit yIT
RECEIPT
JDATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel 17
Combustion Air
Roof Deck 3
Exhaust Fans
O.K. to Wrap
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 de
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
Appliances
Final
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)
COMMENTS: