0002-100 (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 """ a Exp. Date
674174 • is . k O!r �i.rdv
_ t
Date ,/ % Signature of Contract
yl '
• i �� "OWN ER-BUI DER-DEUARATIONON
I hereby affirm under penalty of perjury that I am exempt from.the Con actor's
License Law for the following reason:
( )--- 1, 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 project (Sec. 7044, Business & Professionals
Code). f ,
O ;l am exempt under Section' B&P.C. for this reason
Date Signature' ofx 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:
CarrierPolicy No.
';'A."I'EP'lJ.+tJ? -• 04 6-00073,
(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' 'compensatidn laws of: and agree that if 'l "should become
subject to the workers' compensation -pro California,sions of Section'3700 of-th Le abor
Code, I shall forthwith comply with those:provisions.
Date: 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.t a 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--• � j��
....BUILDING PERMIT ' PERMI�,���►
DATE - VALUATION t24Q3.Ra7,10 LOTy"�''r ..1 TRACT �� �j
JOB SITE, �A2L-T y �1IISU CALICOAPN
��Ie�YS►
OWNER T Y
CONTRACTOR / DESIGNER / ENGINEER
5'R•7E;V' :,
C0Mfs.i:`R€ CrT. )PT ... ., .
P0.90X 1710,
79-295 lUvNC. 140 LA QUIY'FA n y
1 ri TiL1 i22�iT A C A 9Z?'�
1 A3€T N']'A. CA. 9253
(160)77t-1! 41 CBL -1i . "I'M
of
USE OF PERMIT -«
S D-.L0T I PLAN E20- I'l�tMI T DOES NOT FNGL DE 1R. WCi WALLS OR
POUL.75SA KAN C",KEC.K'l+'4", KFIJ Kr ISSUl NCF, O "
SA'Mii;i?I.Atv'XYPEc
- �'r'.ui�'i iZ7l,;vjva'ii�lL:.S 1•a ��iil.VlZ �7R '
- • .
Pili{CCi110 , . t 26S.W S1
,uAK'A.(_wj<:A121'0W!' .1 470.00 S-
,
"MITIMIATIED COST OF e' TSTRUCf 1.01N
C:ONlIrrRUICTIONF8B '101-000-41"00
T, AIN CHKK<G "frs 1(11-f_N10 _Mg _ RR2* 7
E0•'e.AITI`.CA' I;'' `' $1X50
ti' itt�l'f:.'i`k ; 101-C)Ofi-420-� $169.44
PI] dJMi3l,AfC14`T, E 101 -WO -X3.1`4)0 3175.73
rRolq,. .ar+°i r�N e+tir, �O(*-24'1 00'
Cs1LA33WG x a J.01-000-423.000
ARI' IN PA)BUC PL US - RPS -I a 01-1 0,155-000 350.79 •
' LESS PIKE -P )"D FEES .
• SO.QO
' '+1 y,.0 E. A -L PERMIT ly'K'r�C -4 51ti.70, V •
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i �N�:t�..s1i.9.7�/ '.
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A <J
RECEIPT
DATE
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
Combustion Air
Roof Deck
Exhaust Fans
CK to Wrap
jj
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
Y
Final -�
Final
_ _�_� _
POO' S - $PAS
BLOCKWA
A PROVALS
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 Connectio
Encapsulation
Gas Piping
Gas Test
i
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
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)