9907-424 (SFD)i 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
671) }.,�/`� .1iRJ�9.sZ
10 ate�11 �,; / -r � Signature of Contractor } !' 0 0)
r
OWNER -BUILDER DECLARATION'
I hereby affirm under penalty of perjury that l am -exempt from the Contractors
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).
(,) 'I am exempt under Section ' B&P.C.'fnr this reason'
Date Signature of .Owner '
WORKER'S COMPENSATION DECLARATION
I he affirm under penalty of perjury one of'the following. declarations:
() I have and will maintain a certificate of consent to'self-insure for workers'
compensation, Pas. providedf for 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-
Carrier - Policy No.
(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 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 that if I should become
subject fo the workers' compensi I'Ip�j'provisions of Section 3700.of'the.Labor
aC d, I/s II'fo�� �h comply with'thbse prp�yls oAi l
te:' �) It•' Applicant t ✓. j •i ! t(: �f
Warning: Failure to secure Workers' Compensation coverage• is unlawful and
shall,subject an employer to criminal penalties and civil fines u' to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. '
IMPORTANT Application is hereby made to the. Director of Building.and Safety
for a• permit subject' to the conditions and restrictions set -,forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose.request and for whose benefit,work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, .indemnify.
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any•permit issued as a result of this application. becomes null, and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction and hereby authorize representatives of this City to enter upon
thea ove-mentioned prop/ertytffojr'iin.s(pe✓c ion purposes.
v'iSanature (Owne•r/Agent)t f �I/l`G(/f�i? 4 / Dater hy jf
BUILDING PERMIT PERMIT#
DATE i VALUATION LOT TRACT
`
JOB SIT • 1 �+ Yzs
ADDRESS ;1 +t9 3 i.A.17 Jt+9Y1� { , iii ,
APN
604-071-011.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
„If'A;;aPJ'I
ta1.,r<4'RCA ", AND UILI.1AMS �.�,y��.r INC.
77 - AVENUE A iJ OF THE STATES
T Xt FS
P!,um uswr 4.A !3r2211
PA.LNI DESERT, CA.. 92211
('r3t�j34 • a�" f;13LP 3203
USE OF PERMIT
Si't G1 E VAN11LY iUVAL'f.."NC-7f
SFD - LCJi 8 9 y iM INCLUDE iii OGK WAUL (a`t.
POOL, 7�S PLAN S,`fr>1`, K "� FOR W.'iIPLE FSSUANCR OF• .MNIS T? n'T
'i`Si,ACT isCOUSTRt:CTlONN `ry I
POR MP:a` IO 78.€6 tp
GARMOCARPORT h:e jf -00 sp
1,05 ':a4'MATE:D C=Tf O C`C9N�`�'�t3.ri:"I`rti���
r141059100
ERMITTE .'S'$R4'YMARY
t
CION31Ii.IJCTI(yN FEE KOI-{iM419-000 °�Ra 1.30
"� •
FLAN CHECKFEV, 1O1�000-d3t} 31£1 S16<.3N) .
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a�Z�t.`E;."�I,iIC".Fi.I„ i"'C�.; f O i miD6-�y i �T3C)() �t1.i➢€+
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i$jl
LeC:`'iR.ICAL101-40-420-000,
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Pi UR^It�Ii•FCi F4�E dQl.i-o3toA-al+�-fl(�4^1 $1A1.04
ISTJRtit+d�'la IviO TION FEE--. R SIJ .:I01•14if10-..241-000
rRAD>I�Tf.:rl toy wxDo
INFRASTRUCTURE FEF 27:55-4M-443442
AR'r'INPUBLIC. PLACE.% R 3f1:70.1-000.255 1 S.11:1�4�d
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2,�l
S4,822
�tC�'�.'A ;f�$:? 1�7$A' FEES DUE, NIM
J ` TA.n
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
r
04-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-Z—Q GW
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
e,[L
Exhaust Fans
O.K. to Wrap
j_Z _� �`
F.A.U.
Framing
Insulation
T--1 J 9- 0
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
1— J M O0
Drywall - Int. Lath
is . 2 s_ad 14 A(
Final
Final
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
/ 7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
_
` V
Pool Cover
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 av
Utility Notice (Perm) 3s
COMMENTS: