0002-122 (SFD)U)
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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'rriy•License is in full force and. effect.
License # Lic. Class Exp. Date
Date ' Sigriature of Contracto"r; t� `
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*&ner 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)! _' T
( ) 1,'=as owner of; the; property, am exclusively contracting with licensed
contractors• to construct the project (Sec. 7.044` Business &' Professionals
Code)'
( ) I am.exempt,under Section , B&P.C. for this reason
Date Signature of Owner t
WORKER'S COMPENSATION DECLARATION
I hereby _affirm under penalty of perjury one of the following, declarations:
have and will maintain a certificate of consent to -self -insure for workers'
compensation; as providedifor.'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:
Policy Noi •' '
Carrier STAl"H FUND ,'0M6K41.07338
.(This section need not be completed if the permit valuation is for $100.00 or less).
(,) I certify that in the. performance7of 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 Cal lfornia; ayd,agree that if-bshould become,
subject to7the workers' compensation provisions ofrSectlon 37(30 of the Labor
Code, l gs`hallI foKhwith comply with those, provisions.r° .• / ` "' `
Date 1; l:7 JApplicant
i'I ta+
.Warning: Failure to secure_Work ' 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
bf 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 en er upon
the above-mentioned property rof inspectiocrpurposes.'•' _
bl..gnature' (Owner/Agent)
r(Own"" !aza'v�' i nr'R A. • •a+nrJUJate% .t� 3 •r ee l
•
PERMIT #
e/, j- � BUILDING PERMIT.
DATE VALUATION +F §�: �.Q �_, LOT 23 TRACT,/ 293061 �Y , f
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JOB SITE 49-53330 VISTA %A�. CO
APN ti+d9-loij-0A.9
ADDRESS
Y
OWNER r
CONTRACTOR/DESIGNER/ENGINEER
I)1:rs:X.t'rtiEVEIl O1.1 UNIT
4' AJ ar,� � 1,i.., J. 1. l
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PO PDX 1716
u,,, QUIN-A.,Z_rilt.
Lik QUINTA CA 4225:3
LA QU:W`'A CA. 92253
(7611)771-1941 CBIA .2946 ;
USE OF PERMIT�
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WiMLOT 23 PLAN EIR� RETIA41T DOES NOT, TWIXUB L X_ WALLS GR ,
P(Y0L °lX•',�a,'t'+LAN 0010K i=HI tSSU;AN04 01 �
:: r1W F't.,AN 77Y, f -R.
+;,iMONI C CILLS'i PIt:=CFl014 2,61315.00 sr.,
lfN io 267.00 SI'
QARAWC ARPOW1', - 61d.ti17 JS't'•'
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1
ESTIMIATE"D 0,2'03T OF CONST UCT1 ✓'i<
2220.852.00 -
CONSTRAK:T. ON FkM- 1010"-418-p(}0 $1,063.00
'l:f��141s7X"H'1; 101 -WO, -434: >f is $Z1,7 90
4,75CHANICaL:M-18 101-0010,41211000
€. d. etttcAi . � � t atTf3ar► a t�� S162.01
,
.PALUN1111 4-31 FEE 301-000-4194M
q11103r3va?ION F?B 1E51D 101-000241-000
• C'JZAt,[ANC LT l0,1.O43-000 iDI. .G•V
ART 1:N PUBJ 'I:C LACES .• s[c 'l0 i -f4�U- Sg Ufa . ' %302 �_
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Cid = t Yl At . f� CI iS`i r� Tib 4 ANLESS..P A{N CHECK�(}j.y
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VEES
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RECIEPT
DATEBY
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DATE'FINALED
INSPECTOR,,
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footing
,
Underground Ducts
Ducts
Slab Grade
-,Qa 6P
Return Air
Steel
Combustion Air or
Roof Deck
_ / pU
Exhaust Fans
O.K to Wrap
p
F.A.U.
Framing
Compressor
Insulation
p —pa
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
4,31
.17
Drywall - Int. Lath
7 —
Final B
Final
POOL - SPAS
BLOCKWALL
APPROVALS
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
Sewer Connection
��J.t /
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final j
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service fjK
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)