0111-242 (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 # 0c. Class ��"p moi, Exp. Date
Datelwf, "yY
' SignaturE of
.. t
OWNER -BUILDER DECLARATION
)ntraCtor
�. .'✓ ✓
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( s) 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 or.
sale (Sec. 7044, Business & Professionals Code). ,
( ) . I, as owner of., the property; am exclusively contracting with licensed
contractors to construct the project (Seca 7044, Business & Professionals
Code):. ' . .. "
(.) 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.
( ) 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.
9i'A`�'E ��D 046_00"39,
(This
(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 agr�ee'°that,ff I should become
subject to .the workers' compensation provislons,of Sectig6 3700 of the Labor
Code;'I shall forthwith comply wiih those provisions.
Date -/.,'L/&.// f Applicant-/ '
Warning: Failure to secure Workers'
66p coverage coverage is unla ul 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.
a.7 J
IMP.ORTANT'Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth ont his
application:
1. Each person upon.whose behalf this application is made & each person ate,.
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 City1rand State laws relating to. the building
construction, and hereby au,thorize representatives of this City to enter upohn
the above-mentioned prof%rty forr inspection purposeCI A,
Si nature 'Owner/A ent)• r- 'Date
BUILDING PERMIT PERMIT#
DATE� VALUATION LOT '-��� TRACT
JOB SITE
ADDRESS `4}9-Imo'".'�.v'.�tA`AM"�.'A.WELL.
APN
OWNER
DESIGNER EN I(NEER
W ts,<M UrALOPWRNT
vn►ros rv;mLEEo ..
]. O EXYK 1716
7'9.29.5 RANO10 LAS QTQN'1'ADR-
i CA '92213
LA QY�.ti+9'�AAa �a1�e. '��2.i s
(7",60771!-1949.1 CX4 25156
USE OF PERMIT
SPD - 1XIT'n PLA:43 X)& PE TAI J' .VC&S WCXf INCLIMP, BLOCK 'b'1iAi..t;_%
tkC?04',VAOR?.DRdOWAYO.MOAC H
CUSTOM CONSTRUCTION 4631.00 S
' PORCHIPATA 16 ' 26`1.00 SF-
C'3A3 AGEYi" MO T 614.00 hitt
F.&A 'tA APTE)Wd'y+r 'idd COatlS.G.R.'ti'V 4.r•X..Ro
M2'0,8..2.00 ,
FET-CARr FM SUM WARY
CONSTROCTION PRE 7(7:1-00oC 4,1 %-600 $1,06.3,09
MCRA ICAs PYRK 10)"0001421-000 tf.0 .Q0
h !T:�;'; l 8✓;;. 1,PEP, 101-000-A,20-000 $_dVia.iDl
9'Tl�l ibg t VC4 FE 101-000-419-000
STROI` O MOTION N FEE • 9iI31D 101••000-212-000 MAN
ORi`i.DING7 F-29- 101-000.422-000 S20.00
IXI'SS POM PA U) FDS
$0100
'CD's t PLf $' �+kmss DUA ,NOW
9°r��a 4�E
-DEC U 6 2001
WYOFLrAQU6NTA
RECEIPT
DATE��py
("
BY '
'`"
DATE FPD
INSP R
lJ
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
y �� - Z �SUnderground
MECHANICAL APPROVALS
Ducts
Forms & Footings
Slab Grade
2 _ g
�! - Z S
Ducts
Return Air
Steel
_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation 2_1 �X
Fireplace P.L.
Fireplace T.O.
Vents
Grills ®�
Fans & Controls
Party Wall Insulation
' ,
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
��/ �
Final 7-1--15 Z
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 Top Out
7
/" ��`—�
Plumbing Final
Equipment Enclosure
Shower Pans
///
O.K. for Finish Plaster
Pool Cover
Encapsulation
Sewer Lateral
Sewer Connection =�G=Z a�s
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring. _
Low Voftage Wiring
Fixtures
Main Service
_
Sub Panels
Exterior Receptacles
G.F.I.
_
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �_