0002-349 (SFD)LICENSED CONTRACTOR DECLARATION t.
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 af4d
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp., Date
i t•.i�is•,.. +� � -- � / %,1-..ivl3ii�'J(
Date- " ,`+ 36% Signature of Contractor `s t a`
OWNER -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 tlieir sole
compensation, will do the work, and'the structure is not'intended or -offered for
sale (Sec. 7044, BUSineSS & Professionals Code). ,
(„) I, as owner ofthe property, am, exclusively contracting with licensed
contractors to construct;the .project (Sec. 7044,•Business & Professionals
Code).
O I am exempt'unde-r Section-B&P.C.'Jor'this reason
Date. Signature of, Owner
y 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 liy Section 3700 of. the Labor Code, .for the
performance of the work for which this permit is issued.
( I/have an9will 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 •w••''Policy No.
GTWE:V :L'11Gieir LMS. •. de S� Y�4 _b-340V4•n,Ji
(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,
r I'shall 1,ot employ any person in, any manner so as to become subject to the
workers' compensation law's of'California;•and agree that if I should lbecome
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: ;7 v < Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in'Section 3706
of the Labor Code, interestand attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety .
for a permit subject •to .the conditions. and, restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and•for whose benefit work• is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& holdharmless the City of La .Quinta, its. officers, agents and employees.
2. Any permit issued as a result of,this application becomes null and void if
work is . notcommenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days• will subject permitto cancellation.
I certify that I have read`this application and state that the above information is
correct. I agree to comply with alltity, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter ,upon
the above- mentioned'property for inspection purposes.
Si nature '(Owrer/A ent) »aim r i l •`,`t h Date •^+��(j
BUILDING PERMIT PERMIT#
DATE . N2'I2!'; VALUATION 3106,397 •Q LOT ! . ” TRACT
JOB SITE _+ _ �� iv
ADDRESSi�_%{19�9d'6.�i�_(f�ile}L, y
APN r
�0i•lDtl�d.iip
OWNER
}!"
CONTRACTOR? DESIGNER / ENGINEER
7itY Cf;'.�i.'::laL.Z;( ,;'L9T.� :(T?E
�-1'N'1UP.Y �'�.!3 V SLLCo.JNIXI'lNI CIEs,
1535 SO. "D" ;;i'IZ�.r;., ST F. #200
035 ad, "IJ" ,�1'lti_L;1, STr".. ,><20t)
CA:N i3FCNAW)lNO CA_ 92408-
. _ SAN R.P.IWAT- DING CA '9214T8
(909pg1-6007 Ono 2120. •
t . »
USE OF PERMIT
SINGLE FAMILY lD WEL ANG
i
WL'- LOT 69 PLAN li;- PMOT DOES haf INCUO-LIF BLOCK WALLS OR _
POOL. 75Y* PLAV CRECK IFEE RROLIC ..I 0N FOIUNJULT IPIX ISSI(JANCL. OF
:SWvfS PLAN TYPE. .. _
TIti n /,nvI^I,•Y�Vdq.',.Yf r'tl"�'R7F�'c, N ^•.
ti.faF:tt' Olde CA"� OtZT' • 420,00 3
• ��jj``C�•r$'�i6 rt Tv r4-%ve%r,!"t•'AlT�`�'�mY"f0"F"Q'.i'(`61Ll
' .Nati,A k%01,A:d. 1.u•, !',+t yh.YL va�.Y' �.'1l1-Yw1EAW L.R8�1'•!
ab'lr 11ally .CdA
!. [flYq ✓7.EVlD
3 ,y +• L ,�$ ,y
Fa8':1'618'�.I5 Y• �'�+a.F�.7tlJl�U:��HY'iY
CONSTK.,�tiCTIO13 F
7. a v-!e•r a• t r•. r ,. 1e t Po , P
,.OI 000421-0f1010 $47.00
✓
KXOTRI(CAL FEE 101-000420-000 9119.90
RLUM}3W F 101-(i00-4I9-OOis , $137.2-5
: n
c 1z.�l;� cf'r � lo! -000-42 3 -000
DEVELt)E'ET� dt1iPP.t 'I' t Eta
AKT IN P37,MIC PI-A.C.,1WS -'.RESUB 701 -£1011-254-000
Mjk . (".TNIS1'RfRT'fON AND PLAN' CREC
�;� t159 3R
IE S PRE -PA -11) L'EE,-,
4•h An'
"irk 3 KAL 4'ERM1. a .aN EE rS DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
4-1-7 _W AU
-q-'L
Ducts
Slab Grade
Return Air
Steel
. t7- 0
Combustion Air
Roof Deck
it do
Exhaust Fans
O.K. to Wrap .Z 3.
F.A.U.
Framing
Compressor
Insulation
1 ao f=ox
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
00 ca
Drywall - Int. Lath
.va
Final
Final .��p(�
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
r -8t0
Heater Final
Water Piping
-i'► _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
$ (t fj zd
Pool Cover
Sewer Connection
$Lkl, loo
Encapsulation
Gas Piping
Gas Test�(�
Appliances
Final
Final C�
Utility Notice (Gas)L
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power O
Final p
Utility Notice (Perm)
COMMENTS: