0002-111 (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
v'14074 6 � tier ilia()(
Date �' �t > Signature of Con acto`
OWNER -BUILDER DECLARATION
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 nA ryi:"w ftflrA.J Policy No.
016- 0M 73 3„
(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,ra d agreellthat if I should become
subject to the7workers' compensation provisions of Section 3700 of the Labor
Code, I shallfforthwith comply with those provisions./`
Date: !YZ f `1, r .* Applicant % 1
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 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.
y / �..�'''j /?
Signature (Owner/Agent) f`_-' `r` Date
PERMIT #
l.� BUILDING PERMIT 161wZ� s'
DATE VALUATION S"IQ�9.�.ii,�� LOT 1 TRACT 2tA0,41
JOB SITE
ADDRESS i-KOC'.2a�T.+.t�{\k�..R.t.i".�
APN
OWNER
CONTRACTOR /DESIGNER /ENGINEER
SPI, s_.l i9(�',L.'4" :oaf fir "�,''.•'}VA.
1.k) &A 1 r 1c
19-243 RANCHO LA QLAITlA lir...
LA QUI WI -A CA 4225d+
LA QUINrYA CA 922yl
(760)771-1041 MID 2"�i
USE OF PERMIT
"ir04LUi !'1.AN EXAR- KRMIT DOES Nor, j`.i 14C.t rvii' lu V1. K `N ALL4 tJR
,U
4 0(AJa.`1LY'/o = LAN C,11Wb: If 0B X1-:1)UCFION VOR 1xMI 1'lPLF,1SSUANC'ki OF
SARs`PLAN'I PE.
PO.ii YDPAM ZIAS,03 8
C1A1(j1QWCl132P0)V1' 470.00 SIF
l,r�i. i�r�.tsi ICUST 0 th�'i r�.Y b�.a6 i3� wiN'�i
240,1. 17.10
PERMIT FEE SUAINI'1AR
CION STRUC11C)NFES 1€1.OW- 118-0011 $I,±33.00
P1, AN CfF,(''K FFF 101-W-41941 R %731 �k
r vsR..rt r g7ri1 IlliJ01010-41147 0 ar•rry Cn
31`���ilf��LVA4o �'1L 1'tiSi f�*d LA`V�Iti �la''l"...1v3
1'1:! W140 FEE
!i i i�y(113 ; N11>'i`I()3Sh,F"i .1VGi}) 014Y)0 -7414)()P
{moi.
F`• l A r'�'Rrr^e "" 42t" 1,11 A11/1 23 h�7V " ,if. \+al
f�"M
,j
".3�t14�lAV'4) i'L�i'r A" -"'VU `i 41 -� .tip
f?!.V>rilopr_11 i1V11"'A.l';+! .HT1s $1,90.W
¢1W.0 IN. PUBLlr;."!'t.t10ES - RESIC 701-i1M.ZSS-f11i0 S3SU.29 '
C( ill-T()'f'Af. r(')NST;t11CT'io N ANI) PR,AIV ('HI+�'fi(
S4J,1" AA
AIR Fi.' ❑�
L=, , 1'1'4. -IIID ,",
WW
RECEIPT
DATE
BY 4/
DATE FINALED
INSPECTOR
Y
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 — .-pj, AID—
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing _.
Compressor
Insulation p- -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath �
Drywall - Int. Lath
Final
BLOCKW iL PPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines &-72-oz-5
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral 100e
Pool Cover
Sewer Connection ap,Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRIC41APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring 01
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final Q.-2407,97
Utility Notice (Perm)