9907-425 (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. #" Lic. Class, Exp. Date
,
UM
Li/�fe
:d! Signature of Contractor—
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).
( ) 1, as owner of the -:property, -am exclusively contracting with, licensed
contractors to construct .the project (Sec. 7044, Business & Professionals
Code). y
O I'am exempt under Section B&P.C. for'this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION ;.
I hereby' 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, as provided for by Section 3700 'of the Labor Code,, for the
performance_ of the work .for which this permit is issued.
- (J() 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;
STATE FU.47D
(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
sub'P ` t q tFlie Vers' compensation Fo/vislons of section 3700 of the Labor
Cpd6,111 tt th comply with tho6prQulsi�ints>
Applicant
Warning: Failure to secure WorkersCompensation 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
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. l.agree to comply with all City, and State laws relating to the building
construction; and hereby authrize representatives of this City to enter upon
the awe mentioned property foal sp Iq �V016ses.
-Signature (Owner/Agent) + Date
BUILDING PERMIT PERMIT#
�,!zt�7h4'24 ?TRACT
DATE VALUATION LOT
��71�1y73'I.tBet1 �t➢=� , '?,:59�;�
. .
JOB SITE
ADDRESS �%�+�' ��'a i��#.r�` 7I�i�:� �-1�8b��.�•
APN ¢
��-�rJ�•�.�.A
OWNER
CONTRACTOR/DESIGNER/ENGINEER
r
' 1.l.e�r3..[ii3,Vr8 tuA1F.I �ii79.3:.�i:.,8.t'Ct�Y.de3„Ci :: ori A,i`ic.
4�LIPI4`•1,1`�.di..ttd'i•ice�rc'SS�lu6YY.AAS.t'awYf,•�.C., NRC.,
77-NWAVENUF OF.'114F. P;CFL'TES,
77=9W AVENUF 01.4 THE-' ti-,I'ARS)
.Nulh'I DL. Sl wr CA 9221.1
PALM .T ES.ERI' CA. 92211
f°7650}348.262 + RGA 5203
USE OF -PERMIT
Sr -D- LOT”, PLAN N 1H, WALL OR
Pou. 75%. nm G&dY;0K1'Ir , FOR h4UL7'!.PLF, ISSUANCE O SAmr.19LAN .
TYPE
nACT CONSTRUCTWIN 1,736,00 SF
PORrrr fMT70 $8.011 SF
G—ARAQUICARPORT 496,00SF
f .
FEkTNil'•li' ,FEE SCIFTNUMARt'
'w
CO'.N S 1VUiTi'LC. N FEB 101-000-418-000
• " �"
PLAN r1 Ch: f EE ? 01—;3i,�-439�����. 140.19
a�
1+-.% NIC. L PIM 11;1 000 -421 -ow`
E F.CTRICALPIE301-600-420-000
93..71.!5
111.UFYWIiV lG 100 \WI1Y3-(V @�!18
i k
`�'iitG>i�iO ,1(J`i.1C?PF I'£E - ft iE1J 101.000-241-000 $10.48
C1DdJTfdC� F X73 1, Q!-f�sR-11 �' "�-0gd1 �tilq«'
t?wHkYA;i'8'i1Ut� 6' rt2 "lilE . 12,25-000-443-342 0-443-341
Oo • —1 .
W'flMSd;'PLA14 ,iC!-00(3-,x••11-:345
ARIT 01ITU`3f ;LiCPLA.C'iM.4iL fi.` SD1-t?Oli-2 §`uu-{iSiil $11189
sup °�i`:iai�11v4UGjr Arj; GR)aCK..1
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RECEIPT
DATE
DATE FINALEDNS
CTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
—%Oil
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
! (2 -00 ��
I- Z i/ zi
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
- s s -60
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
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
/ 6, r
Pool Cover
Encapsulation
Gas Piping
Gas Test
o. co
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)