0002-345 (SFD)LICENSED CONTRACTOR DECLARATION " r
' I hereby affirm under penalty of perjury that I am licensed under provisions of
Hco Chapter 9'(commencing with Section 7000) of Division 3 of the Business and
c14W Profes-ionals Code, and my License is in full force and effect.
1b License # Lic. Class Exp.: Date
Date '� / i' Signature of Contractor t %^
OWNER -BUILDER DECLARATION ,
I hereby affirm under penalty.of:perjury that I am exempt from the Contractor's
License taw for the'following reason:, _
( ) ` I, 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).,
as owner of the property, arn-.exclusively contracting with licensed
contractors to -construct :the project (Sec. 7044, 'Business &' Professionals
Code).
O I am exempt under SectionB&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.
U/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:
Cartier Policy No.. s
- 001 DH-1+Ia?AC1,E INS: NWC :5 40 63-01
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 Section 3700 of the Labor
Code, I shall forthwith comply with those'orovisions. s ,*
Date: i f 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, 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 City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
4:,,;work isnot 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” representatives of this City to enter upon
the above-mentioned property for inspection purposes. ,
Signature (Owner/Agent) �" t :�' r Date -= b
' BUILDING PERMIT PERMIT#
-'
DATE VALUATION LOT TRACT
'1�n� $132.11981601� 2394 '
L -8
JOB SITE
APN
q��7� ,v�
ADDRESSrJ'tr _ r Ci�'!�tC illeyt
d$�-I1��3--Ri9 +
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
CE -Kr` IN CROW'- ,L t"{'1Mfi4,LYNICt ES
CET,^J`,i'YAY
1'535 sa "17" S'1`urr, sm. #.no
1.535 SO. "D" STREET, STE. 0200 , ..
` 3A.N BERNi1h;DI]NO ' CA • 924tlo-
Ss T .1iL1�,°ti.il`ft_'Lt`it�i CA.- 92408-
��GQ1z81.-r;{i0"1 u CAI O '2120.
USE OF PERMIT
SINGLE FAIMILY DWELLING
8f''D•-:LLT 1 k #.r1N 4C-PEW-ITLv Dd(lrl Y2dE'X Ltt?'!s BLOCKWALLS OR
POOL. Y/ol ,VLAK C14 C34'1•'F.e ftk.L)U(_—.: ON FCiA d4nfTf TIPLt•" ISSUANCE OF
SA..fc:,'PLAN i VIP& -
TJ3',ACf CO SMUCTION 2,2110.00 5F .
PORC IM)A. 'ZO c' n' rr
s i 0n '3 0 �1'V '
CONSTF,U . 014 Y E. -S 10.1-0UU-418-000 $7�13.t1if
MEC'1•l.tt.T'dlQALFti-E, $53.50 t
,g
ELEC1"it CAL rEE 101-000-420-000 $138.20
'Pi LNMAliLNr FEE 101-000-41"00,
Cf`6 i-� .
`STR-ONI N-C)I .f OK
GRUNDn4G MME 101-00,0423-000 $20.00
; f
.E�J�s'��CS�r'E IVP A(:� �'a,9t)f.�ftl
ART ?:t�f 3?liiiWlr'. =aL�LCNS -: 1; 510 :a�1=G0tt�255-000 IK50
ict: -TU 1'A C:C? Si w fC'T.ist7l*T.. I+II1? PLAN CK( -,C1,-
LESS P.1'.i;-1'AID MMES
$0.00
RECEIPT
DATE
BY,/ #
DATE FINALED .
INSPECTOR
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
-Slab Grade
g. tst._ pp
Return Air
Steel
I -T-1
Combustion Air
Roof Deck
Ve ,
Exhaust Fans
O.K. to Wrap
t oo C-gFeoC
F.A.U.
Framing
2& Cb
Compressor
Insulation
$
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�L� �p
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_ -at
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
8
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) o
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 i
Final
Utility Notice (Perm)
COMMENTS:
WESTERN INSULATION, INC.
4211 Latham Street, Riverside, California 92501
Tel. (909) 686-8760 Fax (909) 686-8786
INSULATION CERTIFICATE