0111-237 (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
Pp'140•.74 ;< f3 t ti `���� 07/3 1/2(
Date j t 4 ✓ % Signature of Contractor
OWN ER -113 UI LDEWDECLARATION
I hereby affirm under penalty of penury that I am exempt from the Contr'actor'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
lam 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.
( ) 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 LsTATR FUNDPolicy 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 if4 should become
subject to -the workers' compensation provisions of Section 3,00 of the Labor
Code, I shall forthwith comply with those+provisions.,.•
Date r f , : 1 /Applicant �. ' ✓ j
';Warning:. Failure to secure Workers '"Compensation coverage.,is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1009000, in
addition to the cost of compensation, damages as provided for in SectZ 3706
of the Labor Code, interest and attorney's fees. i
IMPORTANT Application is hereby made to the Director of Building and Safety
for 'a -permit subject to the conditions and restrictions set forth on his
application.
1: Each person.upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to .
any permit -issued as a•result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers', agents and employees.
2. Any permit issued as a result ofthis application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives. of this City to enter upon
the above-mentioned property for i •spection purposes
Signature (Owner/Agent) _ )'a �" Date
BUILDING PERMIT °. PERMT# �•
/
DATE J� { VALUATION LOT �=' TRACT
? ?, / (r. r) UAIAVAO 70 29457.2
JOB SITE'
ADDRESS B ' 1A RVIA F..T��.LA
APN
&V -4W007
OWNER
CONTRACTOR? DESIGNER / EN (NEER
LAgWA1rVA CA 922:3
"f-AQVWA ;CA 929,53
.
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'
USE OF PERMIT
.FFD • LOT70 PLP' V K;, PERMT DOES NOT INCLt;M :BL OC3; WAL I ,
PW4 SPA OR, OMFE-WAVAPPROACH
iy41lz`fi'?V.yATIO 267.00 Sy
t@t�j� a3 lGr9:3i t? '.I 614.00 3F
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A: A':4S�Cl�JG�i,LL- di�'KL1�dr 11SIU 9:aD'JGR$dlL�. X.
COMITRUC'TIO? EE 101-000-418-004) $1000100
1011-000439-M
b1iY-�i0€J 439-ps1+.��y
��;piry
2PLAN
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W L.(;'rRar'A•I., ME P 01-000-420.-000
PLUMB= PER 101 -on -0-4.19.000 6179, 25
:5'FRONO NtOTIOR 1Pr""7 • MID 301.000-24! -000 $32.09
two "'.91 101-000-423-0$s�.40
YJLti�#I75'jpL( IMWL('�.0 ?�Q0'l:
��\(� ( f�9
�Ij�S:��)��t� USE
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°G3,"J C�.�t
LE, .1 PRE -PAID F13-0
Nc
910,00
DEC U 6 2001 OTAL P ITOW
�r .
CI'I'YOF IA
RECEIPT
DATE •
BY
DAT FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
SetBacks
APPROVALS
—/� =2.
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Airc--
Steel
y — / — Z
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
— 2
F.A.U.
Framing
Compressor
_
Insulation——L9�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
G;/- `/�
Final
/ — �% �-�"6 >
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Waste Lines
Water Piping v
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
_ _
Plumbing Top Out
Shower Pans
O.K. for Finish Plaster
Sewer Lateral,/_
Pool Cover
Sewer Connection
y _ g Z _.,p+�
Encapsulation
Gas Piping
Gas Test
. Appliances
.
Final
COMMENTS:
i
Final
Utility Notice (Gas) _
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring —
Low Voltage Wiring
Factures
_
Main Service
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm)