0111-244 (SFD)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty o/perjury that | am licensed under provisions of
*Chapter 9(commencing with Section 7OOO)nfDivision 3ofthe Business and
.Professionals Code, and n9License iuinfull force and effect.
License #`* Lic. Class Exp. Date
Date Signature of Cc5ntract r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following -reason:
( ) 1,. 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 projecty(Sec. 7044, Business & Professionals
I am exempt under. Section. B&P.C. for this reason
Date Signature of Owner
COMPENSATION DECLARATION
1% hereby affirm. penalty of perjury one of the following declarations:,
J 04ye and Will maintain a certificate of consent to self -insure foF 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 37. 00 of the Labor Code, for the performance of the work for which this
permit is'issued. My workers' compensation insurance carrier & policy no. are:
StATE MID
'(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 p I erso . n in any manner so as to become subject to the
workers' compensation laws of California, and agree th 'it if-,4hbuld become�
Code, I shall forthwith comply wit0hose pro�ision�..,'
Warning: Failure to secure Workers' Compensation coverage is unlawfultao , d.
shall subject an employer to criminal penalties and civil fines up to $100,00'0,'- in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's feels.
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
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 td -
any permit.issued as a result of this applicaton, agrees to, & shall, indemnify
& hold harmless the City,of La Quinta, its,offic.ers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
workiS not commenced within 186. diys from date of isivance of such
permit, or cessation of work -for 180 days.will subject permit'6 cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply wjtl� all City, and State laws relating to the building
construction, and herebra�t'Gze representatives of this City to enter upon
Sl�ln
BUILDING PERMIT
DATE I / VALUATION LOT
al U 7 294
JOB SITE
ADDRESS
APN
6490.010-007
OWNER
CONTRACTOR DESIGNER ENGINEER
TMON
L.A- Q(WrA� CA 922S3-
LkQ'fJWrA -CA 92253 --
USE OF PERMIT
MIME FAMMYDWWWQ,
POPE, OPA OR DMENAY APPROACH
CUSTOM CONSTRUCTION Z924.00 SP
POPIC"HWATIO 233.0131 8F
NORIMU YET 90W, AKY
ELIPCIPRICX. F101 101-0000-420-000 $169,24
PLUMBINOWE 101-000-419-000 S1175175
(HUDING KU, 101 -0004tl-000 $70.00
ART al PUBUC PWIS - USE 270-000-445-000 S100.29
WYOFLAQUINTA
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�
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
4/.);o - I
Underground Ducts
Forms & Footings
6=2 - Z
Ducts
Slab Grade
Return Air
Steel
�j . Z
Combustion Air
Roof Deck
- Z
-Exhaust Fans
O.K. to Wrap
�' -`-per
F.A.U.
Framing
_
D _
Compressor
_
Insulation
25- - 5R --0
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation_J
Condensate Lines
Party Wall Firewall
Drywall Lath
Drywall -Int. Lath
Final
�/-� �-��
Final
2,7EM
-
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
Gas Test
Waste Lines
!�/�� g . Z �I&
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
g�
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
- —
Final
COMMENTS:
Final
Utility Notice (Gas)
�p -/d •-2
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
- �i'Y/
Utility Notice (Perm)