0002-113 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under p6nalty of perjury that fam 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 4 Lic. Class Exp.. Date 7
67 4074 13 07i3i'4 t
Date Si -nature of Contr&-C�tto�r:--�;
OWNER -BUILDER DECLARATIOW.
Cto
I hereby affirm under penalty of perjury that I -am exempt from the Contractor
License Law for the following reason:
1, as owner -of the property, or my employees.with wages as their so[6
compensation, will do the work; and the structure is not intended or offered for
sale (Sec. 7044, Business & Profession . als Code).
1, as owner of the property-, am-excl6sively. c - ontracting " with.licensed
contractors to &6nstruct.th6 project' (Sec. 7044, Busiiiess & Professionals
Code). - 2
O I am exemptunder 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 6 certificate of consent to self -insure for workers'
,,
tompensatidn.as , provided for by --Section, ction. 3700 of the Labor Code, for,the
performance of the Work for which this*permitis issued.;l' - I' , IV , I .
I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, I i6r the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No
04"007,333
Y �F rtTr,%
(This section need h'ot'be completed if the permit valuation, is for $100.00 or less).
O I certify that.in the performance of the 'work forwhichthis permit is issued,
I, shall not employ'any persor;io any manner-so.as'to become subject ect to the
workers' compensation laws of California, and agree that if I should become
subject to the -workers' compensation "rovi'gion 6 of Sectio! ;AO'of theiab&
Code, I shall forthwith comply with thoseprovisions,
Date: LiYNAX? �,-Applicant
Warning: Failure to secure Workers' -Compensation coverage is unlawful and
shall subject an employer,to'crirninail'p-enalties and civil fines!up to $100,000, in
addition to the cost of compensation, damages as p , iovi'ded,f6r in Section 1 3706
of the Labor Code, interest and attorney's fees. -
Or
IMPORTANT Application is hereby rnacle t6 the Director of Building and Safety
for a permit subject to th6 'conditions and restrictions •set forth on his
applicat ' ion.
1. Each person upon whose behalf this ipplication,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'off icers,- agents and employees.
2. Any permit issued as'a result of this application becomes null and void if
work is not Commenced 'Within 1180' days from, date of, -issuance of such
permit, or cessatioW of work for 180 days will subject permit to cancellation:.
I certify that I have read this application and state that the itbove information is
correct. I agree t6'comply with all, City, and Stat6'laws relating to the, building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forl!'nspeetion purposes
.-Sig hatu uati
PERMIT#
BUILDING PERMIT
1240 14 20306
DATE VALUATION .. S. LOT TRACT
JOB SITE 4;,-5 5 VIIS14, 'A 1ACO
APN "91-400-0-19
ADDRESS
OWNER'
CONTRACTOR/DESIGNER/ENGINEER
.T,I) Ovsemr- ':�FVu10PN,1EN,-,T
8PARKS CON'STRUC-110N
POBOX M6
79-2195 RANCHO LA Q�1111117A. DR..
QUINTA CA 9'2 2 5 3
LA QUIN-1 A CA 92253
(700)771-1941 MA 2";
USE OF PERMIT
Sr I 14Gf;F_FJVrdT1; . I b%1U1.NG-
j.VtACt%0 NU LUIJ8 BLOC WALLS 0A.
.KX L.75WPLAN CHECK FEE RCIAiCrION FOR. A-10-1 LBISSU C- F
It V AA 8 0
SANE. P.L.AN TYPU.'
CUSTOIM CONSMUCTION S. -V
PORIM(PATIO 235.60 §r,
GARAQWCAKIORT 470.00 8F
ST OF '11TCT
• E STVIATEM M CONIST.1 1011-
• 249J."730-
101-000418-000
K N14 CHFf'1K K- -6 WI -M -439-318 ZW724
11 M,111,1 A -,\q1AL1 'FEE 0 -Jr- JI a -m CA
1114M N V0101 I 'Zo
1 'RCIMC AL FrM
W
f1L'UA&(N GY FLE 101-M--419-000
',52,4 0 1
$20M
KIEVO ;QPM AIPACT FEZ
A-R:r IN PUIMLIC PLACES - RES.ft 701-OW255,40) 1350.29
UFAL CQN.V_ RTJCJ10N.NN-L) pj,�w� (-"mres;
$4.14ZO'A
LESS, I
T M AL PERM IT FEES DUE, NOW
$4,142.03
RECEIPT
DATE
B
"'4
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
.may
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
7
Compressor
Insulation
L _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines `
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWA
%
L APPROVALS
Final
POOL -/SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
— p-
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:
IC 60
a