0002-XX1 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (c6mimencing 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 '
714198
Date
(0) Signature
' of Co'Ptia6tor-
"
OWNER-BUILDER'DECLARAT16N
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 ownerofthe property, am exclOslv6ly contractind with licensed
contractors to-constrkt'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 aiid,will maintain acertificate of consent to self -insure for workers'
compensation, as provided for by, Section 3700 of, the Labor Code, for the
perfo7ance of the work for which. this permit is issued
I have and will maintain w6rkers' compensation insurance, as required, by
Section 3700 of the Labor Code, f6r.thd performance of the work for. which this
permit is- issued. My workers' comperisation insurance carrier & policy no. are:
CarPolicy No. -
rier GOLL)&4 EACIIITA' ;:f6'.`,;544(W-13M.
(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 workers' compensation provisions of Sectioh 3700 of the Labor
Code, I shall forthwith comply with those provisions.`
Date: 0'51ILM Applicant 21&z
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal -penalties and civil fines ul5to $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 pursuant.to
any permit :issued as'a result of this applicaton agrees to, & shall, indemnify
& hold harmless the iCity 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 withiA 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
the above-mentioned property'for inspection purposes.
Signature (Owner/Agent) 14 _W/"0 -A Date z
A PERMIT #
BUILDING PERMIT
DATE TE VALUATION LOT, TRACT -2399M
JOB SITE
ADDRESS R f'R!J�L:F'
APN e.
OWNER
CONTRACTOR DESIGNER ENGINEER
orlIXF114 rDV Cv I Y I t,,r-. NA i r f 17 V
"r
7t,,r,4, T, f y 15 r 1� I,.% nA I L I 1,,, r r I n 0 k T h .1, f I
1535 90. "Ur' irz'01REF'F3 STE. #2100
1535 SO. "Dh STREM', STP- 4200
SAN BERNARIANO CA. 92409
SAN 8FIRMWDINO CA.. 0408
(9r0 )38I -600 2.120
USE OF PERMIT
SiNCA.X
3FD- LOT '71 PLAN 3i"CR PERNIM DOES NOT.WCLUDS BLOCK WALL81 00.
PI(XXI
tZAC71 CONSTRUCTION bt,
635.00 8F
PERMf T F EE SUNIAIiUIV
(;0NS'1,T(UGT10N FFS,,' 101-000-418-000
1 A i r41NA in I nnf% 4P
11 A C A L MCI
rILTICIRICAL
PL UNA3040 VWr 101-000,419-000 $1,x4.75
11),! 4", -?-4*! -Qf.Y)
CRADING F03
$1.90.00
AWr IN C-11J.6U.C, #.)L.ACF-,'; -nsw, 701400-255-000 S75.01
rt
I Srl>}CONSPIP(MOIN ANT)PLAN ('111-ricK
T 'SS PRE Ff
SIG.`
'1'(Y1'A_.L PIP" R 1W ff. FE ES OUIE'NOW.
U7 N1.37,
RECEIPT
DATE
BY,
DATE FINALED
]INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
o 0 d
Ducts
Slab Grade
. Z _
Return Air
Steel
Combustion Air
Roof Deck
(� _ - cc
Exhaust Fans
O.K to Wrap
(i, 3 „g.p
F.A.U.
Framing
Compressor
Insulation
-1 ),gp Cpvzl&
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Co
Drywall - Int. Lath
p�
Final
Final 3( C.2�
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 - 6Q
Heater Final
Water Piping
.bZ —fid
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
I C_
Pool Cover
Sewer Connection
8 @p
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final J� -
Utility Notice (Gas) �pl
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 p
Final v
Utility Notice (Perm) o
COMMENTS: