9907-416 (SFD)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
at' e / Signature of Contractor q10 ° r`� I d
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of 'perjury that f 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).
O I am exempt under Section B&P.C., for this reason
Date'. Signature hof Owner '
WORKER'S COMPENSATION DECLARATION"
I hereby affirm under penalty of perjurq one of the following declarations:
O I have and will maintain a certificate of consent to self -insure for workers'
compensation,, as. provided .for `6y 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:
Carrier 1 �}';I� �•� Policy No. dd l� 9�'•
1 A %1.*1 lei 1' U14D ' - Nc I-r�.7�'-IGM111
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that -in the performance of the work for which thi§ permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if 1 -should become
subiect•to the worker compensation/provisions .of SSe�ction1'3700 of the Laboi
,h�ate111 a%v�o�tthW`tApplicancomply with tfiP�
os$�,i ��l ll��Sr!i
Warning: Failure to secure Workers' Compensation coverage is unlawful and.
S 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. 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 appl'icaton 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 enter upon
the above-mentioned property or inspecfiori purposes:
'rYr��`�'�'f j
we 0KL�
gnature (Owner/Agent) ✓ �' r �' " Date'
BUILDING PERMIT PERMIT# '
• TRACT
DATE / VALUATION_6.� LOT 84
JOB SITE / J -�.
ADDRESS 'V_4io Cb1lLU W JSFA VERDE
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�/'1J 11 �.i 1i Zt�±° :.i VTr1 J r lj NA Ci.':��f0-yQr♦may
rIJE�l,li\J'tI..L�t.1{J h�lP..wl:ili^.1AtlEl.7.CD..1r�+./A.r.yl.a�lis
int' J'��.i`/1 •�+..�g�' �. �"•1 1. tj• Z4 B1." �1 � IS�'J IB.Y,/1
4.f'i+li.7.AJ"4/.'�;1.�1�F.J ��IIL.r��Ir^,.E�.�,.�i 1�v,brrp,iJ•Ei,/.
rl-9(K) A'vEWLIE OR'ME, IMI"fi;US ' .
T7900 AVENUE OF YHE S'i°AMS
PALM lah."S.E'RA..' CK 9.7.21.1
PALM yErrSeeERY CA 912✓"�,j:11
(�
USE OF PERMIT
SENOl.,P,;t"A4V;`fWV t~:1VIP.ULNi"v
Sr 11) 3A,•PiwRMT'001FS Nai U,"C LIZE, IMLOCX W.M.f O13 w z Y
POOL. 'dSao $'.1 AV lUffP'.'C;K FFE FOR MUE.IIPL E. TSSCdANVE OP SAW, PLAN t
-
• �
•i
1.y:Ma i k.. �
TRAe~,x CONSTA 2UC.'i10N 2.n'7JC.00 Si
PokC.ESfPKC4.0 1120.0 S.F
OAlliW&CARPORT
. ~S1A[iAR��'A:c1I 'WaJ,i1. 31 4.4.IL.'k \:Y .b .O I�J i..r �.W,'LeS 1.
.PERMIT FEF, S$J.WWAM
CONti'I-k(JC!f(ON FEE 101 -0004;M -OW $'1;6.f1i1
'AN C 4T,CK FEE 94}4�ti�O.:t�� �lK glt ifi9'
i EQ.11ANs^f'+.1, r E 101-000-192; U6,50
Ek.I��`.Txt tf,r'a9:::3' ..��1 i-�'D()�_t�2t�-C€511� $150.48
PTX%1UING FEE 10140-14 19-M �2't"l.Sii
swRriNe" monr�r l..T;aJ 101 -000-2.11 -000 $: 5 �
aRFlDii'\f s FEEI 10,1'-000-42.0000
iT�fE'>t�a 9'(:.isC'TS1kiL"F98
VrHEC;t:` E PLAN 101-Ot}(►•-441-345 s, I)
ART 9N P VMTC iii'„{ CF3 . R!-NI1Y .701, 0f'i(112 )-9(V �Sn6
SZtBITYML C;c,A1vYS'1'itVQ NON �VDrLAIN'HECK. .
..0ti/
EESaE%S ;
"ALLJFEES
$tl?0>
_TfffeEJ-1 WGliIL@FIS .NOW
- ��i;�ViD�O•.Y .
RECEIPT
DATE
BY,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings9/Z= C
Ducts
Slab Grade lye ;7=f" L
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing i— 7 -t -4m
Compressor
Insulation 2 -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 2, — 14 .- to '
Drywall - Int. Lath
Final
Final
POOLS - 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
Pool Cover
Sewer Connection toEncapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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) .-Lt _