0002-123 (SFD)LICENSED CONTRACTOR DECLARATION
I h`areby
affirm under penalty of perjury that.1 am licensed under provisions of
H 'hapter•9 (commencing with Section 7000) of Division 3 of the Business and
C� U) Proi-ssiohals'Code,' and my License is in full force and `effect.
O =)eh 000� ase t1,, y- Lia Class „ Exp. Date T e
.,
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rre0LILI
Z Date 7'/ {! nSignature of Contractor'
rl- U � OWNER -BUILDER DECLARATION•
WW I hereby affirm under penalty of perjury that I,am exempt from the Contractor's
License Law for the following reason:
•- Z (.) 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).. « ,
( ) 1 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
LO
Date "' K ` Signature`of Owner '-
0,� ;
Q WORKER'S COMPENSATION DECLARATION ^.
) I hereby affirm' under penalty of perjury one of the ,following declarations:
Lin O {) 1 have and will maintain'a certificate of consent to self -insure for workers'
X W compensation,• as' provided for. by Sectioli 3700 of the Labor'Code, for the,
-O J Q performance of the work for which this permit is issued.'
m Q C) ( ) I have and will `maintain workers' compensation, insurance, as' required,by
O U Q Section 3700 of the Labor -Code, for the performance of the work for which this
CL � Z permit is issued: My workers' compensation insurance carrier & policy no.* are:
Carrier Policy No
C' 5 S 1 A I L :tm°z1�.R? • a' W16-_f3`t'J'733E
Q (This section need not be completed if the permit valuation is for $100.00 or fess). `
(;) .1 certify that in the performance'.Of the work f6 r. 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 thatif I should become
subject to the workers' compensation provisions of Section 3700of the, Labor
3 Code,1 shall forthwith comply with those pro, isions?
Date: c1- / 1 Applicant
Warning. Failure.to secure Workers `Compensation coverage, is unla iful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition.to the cost of compensation; damages as provided for in Section 3706"
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a' permit subject to .the conditions, and restrictions -set foith' on his
application. M
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed_ under or pursuant to
any permit issued as a result ofthis'applicaton,agrees to, & shall, indemnify
Va
&.hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result -of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation:of work for 180rdays will subject permit•to cancellation.
I certify that l have read this application and state that the above information is
• correct. I agree to comply with all City,•and State laws relating to,the building '
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pioperty'for inspection purposes f '
4�, b/ BUILDINGRERMIT • PERMIT
DATE VALUATION LOT LOT �4 y,� " TRACT �()�
JOB E
ADDRESS 48-J�.3D �f &.s`S lk C_,.m o
ADDRE
APN 64; i
,
OWN�EyR•+
CONTRACTOR /DESIGNER/ ENGINEER
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+ll..i.i.~iw,J(.��.�:7�L(�$fi'.'•. �:ri' -fi'��L.C�;V
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P(3 O -1716
79-295 RANCHO LA QUIN'hk iM t
I.,A QI s Wk CA 92253
LA 7UINT1 CA 92253
C760)771-11941 C: tc. 2904 .
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USE OF PERMIT
N? iV ti.l�rt�'. I.^`/'1tN41LY DWELL I G = .
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PO0L:7,V/a 1%i;AN CI•f.EX'K F'F : fd )UQ.T!.0'N FOR iv !J T11P1E.1SSUAN?CS OE r
: i US -102M CONN rRU i tON `�,Ei3J:+�U sr. � s
N -S iNIX..0 COST OF CONMIRT:TC710N M'10,852. 0
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C,ONSTROC71 N FEE . 101-000-418:000
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av�vr>,..i�>,.:�a '• -00041`1'•uuv r- .Uay.i.Lty
7-' t Ti tc,'�►1,1 - ` , 101-0004,20-060 a t�2.�iis
Iii U��rz3+�vc� f 101-0 30 -419 -IM 1174.25 � .
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1v€i/ii°t.liyit2ll�il �+7`�! $1,.ui:isG - T+
AxCf !N PUBLIC'PLACES-1CcE34-C 1Li.1-!)G't} X53-(?t)t3 S302113'
SUB- AL C(ONSTRUMON1 AND Pl,AN (';HE K 1$3,9793R
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FEES
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RECEIPT
DATE
BBY/DATE
FINALED
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dry
INSPECTOR ,
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INSPECTION RECORD
$*OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings WDucts
Slab GradeReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap _ a 3--
F.A.U.
Framing -7 - �a ,
Compressor
Insulation ef 30_o -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
Final - Z
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�yy
Water Piping
Heater Final
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 —,o�0
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 100,
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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