0111-232 (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
Date/•: -- / .fP 7 Signature of Contractor
OWNER -BUILDER DECLARATION /
I hereby affirm under penalty of perjurythat 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).
( ) 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.
( ) •l.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. 046-MI1M'1�t'1b
.�{�`�'.'�'� FUND
,(This section need not be. completed if the permit valuation is for $100.00 or less).
(•) I certify that'.m; 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 Cal ifOFfiia, a%d agree that if I should become
subject to thefwo`kers' compe%nsation provisions of SectlougF3700 of the Labor
.Code I_ hall forthwith comply/with those provisions. r
Date.;:. <�. f Applicant
N _ ....»
Warning Failure to secure Workers' Compensation coverage Is unlawfll 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 a
whose request and for whose benefit work is performed under or pursuant t ®�
any permit issued as a result of this applicaton agrees to, & shall, indemni D
"& hold harmless the City of La Quinta, its officers, agents and employee .
' BUILDING PERMIT FERNY#
DATE i p 9 VALUATION LOT 9111"2 -2 TRACT
6 Aa0,117.10 65 294574
JOB SITE APN
ADDRESS u u. VT Z A% .649, l
OWNER CONTRACTOR / DESIGNER / EN (NEER
Tr,1^?1; ?Rr 1 EVKtJ_4'1 f SPAS t':O)WRT1+G' ION
C.!i. 92233 ukQ"i11MA C.A 92253
(160)77'1.194). MIN 29,4s
USE OF PERMIT
=0111el Yw.Ei, y DW1W11 G
SaD . L01° 65 PLAN X2. SaNMI1' DOES P;L7T INCLUDE 91,00 WA IA,:jP0014 �RA, OR DRIVEWAY APPIRCIACH
PORCHMATIO 1.Gn SP,
470A SF
1 COIST OF `a,f.✓57VIR11J9..•a.d1�: 0
� df"367g.8v: 9,10
p�4.a7AId.Ay�,;2�7
��yygg nn����aa y� yy;�y �v�yg/Qp�,�r
:II:� nE.S.ti3i �I•�E Sb 91 YW.Di'77.4�3'C.�7L.
-CONsTRUC° ION ME
1.01.000.4.18,.t100
$1,133,00
WMANICAL FEZ
101-000-421-000
$130.50
E1r1'�&T1bX'C.AL d• 7a
101 -000 -42G -WO
$169,X4
F',LM-SM0 111.9
'101-000-40-040
$173,75
S°k'RONC3 MO'';IION IYfiR R;ESID
101-000-24,17000
$24.01
011MMOMt
1G�1�t3GA b 'a-00
$,2ArAd
ART IN. 270-000-445-000
$100.39
_ xS
2. Any' permit issued as a result of this application becomes null and void DEC 0"6 2001
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information ' C9TY0FLACg91WA
correct. I agree to comply with all City, and State. laws relating to the buildin 6�n'a���^�$7 '
construction; and hereby authorize representatives of this City to enter upon?
the above-mentioned property forinspection pbrposes
P. RECEIPT DATE
Signature (Owner/Agent a ` �f ?Date r'?� F
BY//nn'�
DATE FINALED
JA_ :?/-.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
nderground Ducts
Forms & Footings
j�� —�
t
Ducts
Slab Grade
•- / _
ReturnAir
Steel
5 —, Z
Combustion Air
Roof Deck
, g _dam
Exhaust Fans
O.K. to Wrap
.—pZ
F.A.U.
Framing
—/y BL
Compressor
Insulation
/G -
Vents
Fireplace P.L.
-
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
�
Condensate Lines
PartyrA-%-
Wall Firewall
Exterior Lath /
Drywall - Int. Lath
T,), ma
Final
I
Final
_zS_ A&—� .
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Y
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
-2S
Electric Final
Heater Final
Water Piping
_ _
/ ��� '
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
/
"_ l�
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
J
3/ _2:z--2
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
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
l//
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
�--�-_