0002-360 (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
114188
Ps�:Z'! Signature of tract -or 4
[Date Con
C/7— \7
.OWNER -BUILDER DECLARATION
i hereby'affirm_under penalty* of 1perj6ry.ihat.l am exempt from the Cont'ractor'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 stru - cture'is not intended or offered for
Sale (Sec. 7044, Business & Professionals. Code)..
1, as owner of the property, am exclusively contracting with,Jicensed 4.
"contractors to construct. --the project (Sec. -7044,, Business & Professionals
,Code).
I am exempt,undir Section' ','B&P.C. for this reason
Date' -Signature of Owner
WORKER'S COMPENSATION DECLARATION •
1,hereby affirm,,under• penalty, of perjury one of the following declarations:
I have an d,will maintain a certificate of 'consent to self. -insure for workers'
compensation, - as.prmic!6d-for by Section 3700 of the Labor Code,.for the
performance of the work for which this permit,is issued.
(JAI.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. ay workers,' compensation insurance• carrier ,& policy no. are:
Carrier Policy No.
(This section need not be c'omp*letad if. the -permit valuation is for $1 00.00: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' compensition laws of California, and agree that if I should become
Subject to the workers' compensatiow provisions of Section 3700 of the Labor
Code,- I shall forthwith comply with those provisions.
Pate: I I Applicant I
z��.4
Warning:, Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer tocriminal penalties and civil fines up to $100,000, in
addition to the cost of_c8mpefisatioin,- damages as 0 . rovidedJor in Section 3706
of the Labor Cocle,intereit, , and attorney's fees.
IMPORTANT Application is hereby made tolhe 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 trenefit work isperformedunder' 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 o ' f 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
-qonstruction,'and hereby authorize representative§.of this'City to enter upon
the'above-mentioned property
- p ro"pe ryfor-inspedtion purposes.
.:,-
1.
Signature (Owner/Agenei\,
Date
PERMIT. PERMIT#
iBUILDING
DATE -7--) VALUATION s . �0=1 - TRACT
J.".097.60 1-3995_8
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CEP "iii VVICRROWELL C()MhSJ.N1T1,qS-CE-WRJRYCR0'ffEL`
rs
LCOMNITITINME 3
1535 50.!V` SMEU� STE. #200
1-133 SO. "D"SlIRRE L - 9T E. 4100
"
SAN URNAKERNO CA 9,1408
SAN, BERTN.''CK 92408
2.1.20
USE OF PERMIT
SINGLEFFAUTLY-DWELLING
S.M. LOIV.1779 PLAN' 2C- PEnff DOES NOT WC BLOCK -WALU Olt
POOL. 1;'43t0 PLAN CHECKF.CF, PXiDUCHON FOft 11"tUG'11018 ISSUANCE OF
SAM_'E PLAN TYPE.
IM-kc,10 CON Sr
P0RCWPA:Rd 31-1
.
•
TIJERMITFEE SUMAJARY
r3ONSTR43C11014 FLTi 101-000-418.000 V i I 15A. (k)
P AW,r
$47 .00
YZ 11 CAY FF -F,
J BIN U F M-1 1101-000-419-000
PLUN
..TTaiv pwF im-up VIn A4
DOVOLOPM tVIPA&T FTX7
AWf INPUBLIC PLAC S - REsID701-000-255-000
FK FAL CONSTRIA, AND PLAN C -IECK.
KiD T 3
4
LESS PRE -1 fb ES
$0.00
TOTiM, PERAiT1' :FFX8 DUE NOW
RECEIPT
DATE
RYDATE
FINALED
JINSPECTOR
.06.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
. j
Ducts
Slab Grade
Return Air
Steel
t
Combustion Air
Roof Deck
r -020
Exhaust Fans
O.K. to Wrap
Framing
(p • -n =40 AX
$ j)) X).0 1=Ci,(
F.A.U.
Compressor
Insulation
8 • g• 00
Vents
Fireplace P.L.
Grills
Fireplace T.O.
-
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3 t m
Drywall - Int. Lath
00
Final
Final Il
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
—(t iQ0
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
yft"
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 is \oa
J
Utility Notice (Perm) Cot—
COMMENTS:
WESTERN INSULA'T'ION9 INC`.
4211 Latham Street, Riverside, California 92501
Tel. (909) 686-8760 Fax (909) 686-8786
INSULATION CERTIFICATE