0002-117 (SFD). Y
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
674074+ b 07/31r2Oi
Date yet n Signature of Contractor'
1 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). - r 1
O Lam exempt under Section, ' B&P.C. for this reason 'J
Date Signature of Owner
' WORKER'S COMPENSATION DECLARATION
I hereby. affirm under penalty, of perjury one of the following declarations:
O I have and will maintain a certificate of consent to self -insure for workers'
e' compensation, as. provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.r
( ) f 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
y permit is issued. My workers' compensation insura_nce.carrier•& policy no. are:
Policy No
Carrier •
S TA` E FUND 046=7334-
(This
l $-=733S(This section need not be completed If the permit valuation is for $100.00 or less),
y (•) I "certify that in the performance -of the work for which this permit is'issued, "
I shall not employ any pe'r'son in any manner so as to become subject to.the
Workers' Compensation laws'of.California,'and ,agreeahat if-lshould become
subject to�therworkers' compensa�n-provisiTs of Sectio 3700 of the Labor
Code, l shall forthwith Comply with those'provlslons�
"S .rfi 1
'
Date: /i%�7ri- "Applica�t,:�'"__ !""" `
Warning Failure -to secure Workers''Compensation coverage is unlawful and
.shall subject an employer to criminal penalties and civil fines up'to $100,Or00,in
addition to the Cost of compensation,,damagesas provided for,in Section 3706
of the Labor,Code;1 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 orpursuant 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 iesult of this. application becomes'null•and void if
work is not commenced within 180 days from date of issuance of such
permit, orcessation 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 prop rteyfor inspection purposes. /
I Signature (uwrer/Agent) - ” �✓
ci PERMIT/t ,
t BUILDING PERMIT 1�1.►���.��r ?�'
DATE VALUATION S220AJ2:4'j® LOT, . IS ' a TRACT - 2.2P3ttFi � •
JOB SITE
ADDRESS 4.3-X45 V15TA �[ULfC0
r
APN 64946,M)1511
OWNE�tR^�
CONTRACTOR/ DESIGNER/ EEN9GIIN{EEERq'
y�
' pi lJ l',�'s3� Iff n�iir3.R'.4.1/•t-j.�ai' i�'3 1 '
1 r,9i",CAll.i .�'t '��i i.?,i`i i,�`i.tw.l 7.OiY i
0 Box i _17 i6
79-295 FUMNICHO LJ Qi71MPA iDk,
LA. QUlfN1't, i�!A 9r153
I.A. Q1.JiiU''1'.A ' CA 92253 -
1
(760)771-1941 CBL# 29% ,
_
USE OF PERMIT 1
PERWAUS OR
SY1 -LOT 18, PLAN ETR- MTi DOES NOTT I,iP1�E;t� .Ck l
i?+i L..`?5%i°LANC"<HEdX'FH6TWU't;:L'f0NF6AM0,`I`iPLF: .IS,,-,UNNcE0
J r'
SAA1rifi:P1 KIN 'T'A'PE.
. 2,635 ,00 S:I'
fAMOIDPAII 267.00 9V
dl.AftA rE1QA,k110f?'F 6 14.00 $3
`• �` ''
'eISTI1vILVI�l) COST 01? �,.ip{`iw7.+ RUCTIVOIStr
..6c44/�t3J� di� • • .
{ ` ■ y ■■ .�^^,,
MAKV
9NS'11RUC`I'IQT3 n 1;C;3,0U
P1,AfJ 01.9r, CX
Yf�fu4rt r'rlrt'!•r pp 1. y .i /17 f/��(/j�rr1 '1 Z ,.((j{J/Qq{{�� @@ r ((fi�r P
l 1 CL/9J,�fAGA�L )�fi1� SVi"VVN"'�'b.l!•1Ptl{J. - itlr
r .
• � .�
Et EOTI .iC a 1�ii-t)GG-�t24i-0Gii 362.Ui
1 '
P. {y�)�t.�^14r(:.!','. 1 1QN'0�"^t:Z9"'00%'i.�.
9'$ F{(1YSfislC�Ti��t�T itF41l 101 -00-2[fi-w
•rc'f n• rLf•
t:,...�,�?tNG.t�:�..-
i3l it'i .l►.t�i :j 1W, AC 1` 11i1 S,1.H0'1.f30
A.:R`L' 1NPUBLIC +'t.AZ-'FS - R.f SIL70a-4x 0-255-000 SM21 t3
ia:B-TO f -A CON S'x'9Z.iTCTION :�,.�"n _�pv� AN C1 EC��c ,
$�yu7g z�
� +
.�'.,
t
RECEIPT
DATEBYE
DATE FINALa
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
le
Underground Ducts
Ducts
Slab -Grade
Return Air
Steel
Combustion Air
Roof Deck
,2�� pZj
Exhaust Fans
O.K. to Wrap
/
F.A.U.
Framing
7--v
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
Final
Final a
BLOCKWAL PROVALS
POOL - PAS
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
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. or
Smoke Detectors
Temp. Use of Power
Final — (j
Utility Notice (Perm)
COMMENTS:
M