0111-273 (SFD)LICENSED CONTRACTOR DECLARATION
ereby 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 LiceK6e is in full force and effect.
License'# Lic. Class Exp. Date
5 5
517 M B 7,1 -10z
Ate/,f Aet-' Signatureure of tract
or,
OWNERBUILDER DECLARATION
I hereby affirm under penalty 6f 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 project (Sec. 7044, Business & Professionals
Code).
O 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 , I Policy No.
STATE YUND
(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'
a '7700 of the Labor3
subjp�t to the workers' compens tion--orlovisib/ns of
Code, I shall forthwith comply with those'provis ions
Appljc;ini— — ------
Warning: Failure to -secure Workers"d.ompenisation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
.addition to the cost of compensation, damages as;orovided for in Section 3706
'of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the.D' li'rb . ctor of Building and Safety
for 'a permit subject to the conditions 'and - restrictions set forth on his
application.
1. Each person upon -whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the -City of La-Quinta, its officers, agents and employees:
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within,: 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize-repres6ritatives of this City to enter upon
the above-mentioned prope nspectiompurposes.
Signature (Owner'/Agent)-'«e Date 4'b Id, ")I
.'.'BUILDING PERMIT PERMIT #
DATE VALUATION LOTa TRACT
140'.
JOB SITE APN
ADDRESS`
I OWNER CONTRACTOR I DESIGNER /;:NhINFER
MCI
il.01140X IV,$ -
1A Quix'm CA 0253
)WICUO CAPI,'T1'.QJW C� JDA!,14T11 0T'MhNT
79687 C0UNT.RY-(XZ713,.DR#Z0'1
CA 92201,
(15i* 1969
USE OF PERMIT,
S14) o '.rVr 10 PLAl,' ?-A WITH CX',fTA. PkNWITDOES 14OLT I CLUDHE
BLOCK IYAUX, P004SPA, OR DRTV&WAYAPT)_R,0ACH
CUSTOM CONSTRUCTION 3,SS4,0 0 SFI.
POR40-h"PATIO si?
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RECEIPT DATE • BY/ DATE FINALED INSPECTOR,
mwmw con or commuccuoN
PERM-fr FAXI 9UAMA RV
M
CONGTRUCTION "
101 --41 8-0001
OW
ss,nuo
PLAN CHIECK VEX
101_000-139-31.8
$1,104.75
'14WHANICAL Fff
101.000-A-21-000
$153,00
KLXCTRJ'GAL r
101 _000-420-000
1131.99
PLU'MDFN0 FE?
101-000-419-000
$223A
STRONO MOTICY14 FEE • RESID
101-000-241-000
VI o. r,
0R.A.D010 FER
101-000423-000
$20,66.
DEVELOPZRI IMPACT FEF,
,q.00
ART IN PUBLIC, PLACE'S' • RESM 270- 000-445-000
046178
FROZ 0h POSIT
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RECEIPT DATE • BY/ DATE FINALED INSPECTOR,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts _
Slab Grade
/ Z
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
.. $- Z
F.A.U.
Framing
Compressor
Insulation
G p Z i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
2 -dam
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Water Piping
{
/. 7 l
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
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
Utility Notice (Perm)
COMMENTS: