0002-114 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am -licensed under provi.siohi of
Chapter 9 (commencing, with Section 7000) of Divisioh 3 of the Business and
.Professionals Code, and my License is in full force and effect.
d' License # Lic. Class Exp. Date
67.4074112.0.i
Date '&46atur' of Cn4trzrtn
Signature
OWNER -BUILDER DECLARATION:.
I hereby affirm under penalty of perjury that I am exempt from the C: 7tract)or's
License Law for the following reason:_ ' - '. " , ". %. If
t.. -
1, as owner, ofthe* 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 th I e, property, -am exclusively I contracting',w'ith licensed
contractors* to= construct , the proje6t (Sec' 7044, 'Business& Professionals
Code).
O I am exempt under ,Section -
B&P.C.,for this reason
Date Sidnature. of Owner
WORKER'S COMPENSATION DECLARATION
-1 hereby affirm under, -penalty of perjury one of the following. -declarations:
O I have and will maintain a'c*ertificate of consent to self-insufe for workers"
compensation,- as I -provided-for, by, Section 3700 V the, Labor Cod6; for the
performance of the work for which this permit is issued: sued
I have and will maintain w orkers' compensat I ion 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.".
-U, 4 6-0007333
hr
ATE f, J 04
(This section need not be'comoleied if tk6 permit valuition is far $100.00 or less).
O I certify that in the pewrforriiance`8f the work f6r'which this permit is issued,
"�s me subject to 1he
I shall not employ any person in any manner -so )to become
Ile, and
; I , *
workers' compensation. laws of,California, and agree,Ahat-if I should,'become.-'�
.3.7-0 0 of Labor subject to tfie.w.Aeri' c6rhpensationFprovisions Cif Section' e a, or
f
-ode I sh
all foKhwith comply with those provisions,."
Ko.
Date: LP-04tq I'. 'Applicant I
Warhing: Failure to secure Workers' Compensation *coverage 'is% un'Lwful and
shall subject an em
ployer,to criminal penalties and civil I ,fines
, !upto$160,000,in
addition to'thd cost of compensation,
damages as pro'vided'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 t
' - pirrit -subject to, the conditions -and restrictions; forth on his
0
application...o -
1. Each person upon whose behalf this application is made, k-ekh� person at
whose request `and for, whose.benefit work is 'performed under or pursuant to
any permit issued As a re ' sult,of this applicator agrees to, .&'shall, �indemnify
& hold harmless,the City - of - La Quinta, its officers, agents and employeds. -
,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 alk *City,. and, State laws relating to the building
construction, and herbby authorize) representatives ' -of this City,to enter upon
the above-mentioned prop6ty for inspectio-n Fbrposl— :0
Vi
PERMIT#
BUILDING PERMIT •
DATE VALUATION T122%852.00 LOT TRACT,
JOB SITE VISTA CALICO
ADDRESS
OWNER-
CONTRACTOR DESIGNER ENGINEER
M r) r. SER, T D E %M. 0 Dil�v A, IF Ir
'STAYUKS' C ONT MUCIF10�1111
P0 1716
fr
729S kWWC140 LA QPK rli.Dk,
CA. 9225-3
LA QUINMA CA 9225-1
Q(50)7711-1941 Cel,it 29%
MIT
USE OF•�P�EIRR.
tYWV
SM -LOT 15 PLAN 41F, RERNOT ]DOES OT INMUDE, BLOCK WfiLLLS 0A.
1100L,75%.PLAN CREM FEE RETIUCT iON FM_ MUL'f1PLH ISSUMCE OF
SAM'13 PLAN17YPE.
CUS ral CONSMUCTION 2,63t,.00
pdaafo A WO
MMM 'S 11JUMP't
L C09f Or! CM, T1
220,352m)
HM'AUT FER'SUUMA-111"'
CONSTKUCTI.ON PEE 10.1-000-413-t100 gl.€i aoo
_PLAN CNE0,4'. IFY-F,t 01 AM, -0931 8 R! 7.90 -
11 MMICALIM lw000 - S-105,00
ELE-Q-TRI, ICAL'�-&
101 -M -4i9-000 $179,'_;5
11"Um ING Ms 101;-000-1223-000'
OEMOPER -IMPACT HE
Awr iN Pumic N.Ams -.RE"SW -701-000-2-5.5-000 13
SUB-TMI A -L. CQN,51 TRIX WN ANDIPLAV CRECK,
tow
$3,971R,319'
IIESIS PI'S -PAI D FEES
10PU0,9
'NOW
TOTA), PERMIT FEES WX
97*
RECEIPT
JDATE
C
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—p -d
Return Air
Steel
Combustion Air
Roof Deck
a —
Exhaust Fans
O.K to Wrap
Framing
/A
F.A.U.
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
- r
Final
Final
BLOCKW
L APPROVALS
POOVS 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
—Oa
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: