0111-235 (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..Qate
67014
DateFf' „T! Signature of Contractor a !
OWN ER-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).
( ) 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. 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 workais' 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.
. i3T;�'d'� :1�'4>'1+7u . tf4i7•�f)•tl7?J;�
(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 to the'worl�ks' compensation provisions of Section,3700 f the Labor
Code, I shall forthwith comply with those'provi�ions. "
Date: /.w.. fY Applicant'
Warning: Failure to secure Workers"tompensation 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 pursuarit 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 s
the above-mentioned pro � rty for Inspection,pu .rposes.
Signature (Owner/Agent)t _ !3 ! -�� Date'
BUILDING PERMIT PERMIT#
DATE h
�. VALUATION LOT ^ TRACT
,� ti 6� 2.45? -
JOB SITE APN
ADDRESSg�-,M1q��yr7
OWNER CONTRACTOR/DESIGNER/EN INEER
11110 BOX, 716 9.295 JUNN HO LA OXNTADR.,
;CAq'IN A CA 92253 LA,(2tr1WXA CA 92253
(iM)711.194] COLO. 2996
USE OF PERMIT
MOLE Rw", MM LING
S FID - IDT 69PIAN El. DOES NOT INCLUDE fliLtXX WAi.L%
�00� .E!•?t�, t;�I'G.l}Ii.['�''�i1�:�S''.R�.�k"Fi��C.°i3
CUSTOM COMYRUC°TION 03%0.1 511E
pE3i'.Cfi��1�.A'1'1C3 �57.bt) air
0 1,11 K7ARPORT 614.00 SAF
EaMA77'.0 COST OF d."t?:t<i'6TH't7'C 220A52,00
CO'Nii;TRUC;TION FRE 101.000.1418400 $1,063.00
PLAN CUM,' ME lot -00".39-318 $117.90
101-000-421-000 9301100
133,RC T IZIC,A11019ft 101 -000 -420 -WO $,162.01
1,111U A.ff INQ FFF 01.000.419>000 WPM
STRON10 RIf,O'Y'1£3N FEE a M-00 101-000-241-000 W.09
C6yk,?s KANO RZ 1 it l -000-4 c3J 40th 00100
0FIV I'.1.d"pla lmPIACT FEE $1,90.00
ART I14 PUB1.40 Pl,triCM - Mir 270-000-445-M
6
t
ffn -YoT.AL 6.6•ogmI.1'oa'Iav Ax k'1 na amcx ,728.38
PPM -11111M TOM $0.00
DEC 06 2001
E ' 1
'BY DATE INALED INSPECTOR
— - y
- F .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/�=f� -Z
Underground Ducts
Forms & Footings
Ducts
Slab Grade
- - Z
Return Air
-
Steel
=/ff - L _
Combustion Air
Roof Deck
ell-// :
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
��
Compressor
Insulation
Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
e
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath��
Final
Final
�v ��
POOLS - SPAS
BLOCK LL 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
C_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
ZPool
Cover
Sewer Connection
.y _ CJ .L .vim
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final<1
Utility Notice
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
v�
_ U a yo
Underground Conduit
Rough Wiring
_/ Q Z
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
_