9911-084 (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 # Lia Class �. Exp: Date
ypate 7'' ! Signature of Cohtractor�'
i 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•their sole
compensation, will do the work, and the structure is not intended -or offered for
sale (Sec. 7044; Business & Professionals Code).
( ) I, as owner of the property, am exclusively co'ntractind with licensed
contractors to construct the 'project (Sec. 7044, Business & Professionals
Code). x
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 'LaborCode, 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 . Policy No. '
:GOLPAP"N'SAGLE, 34
(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 th'e .
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 provisions.
1 ` t°_• iii' /-•
Date: ti l:,-, / A/ h' 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 perso i. at
whose; request and for whose benefitwork is performed under or pursuant to
any..permit issued as a result of this applicaton agrees, to, & shall, 'indemnify
khold 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 ofissuance 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) -a ' �1 + �_ k, Date
PERMIT"-
BUILDING PERMIT
DATE ! VALUATIONLOT. TRACT13 y�ti j
JOB SITE
ADDRESS i8-�''�.. WMGI �.IL��LD L�:.�f�t�...>'L E
APN 04-040-016
0.016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
l(�`3+�';"t
I awt s . �' �"1' i >r, " ' . #f} G��
1535 30".Do Sp cl , CT, v`m.
SAINT BeRlafE`cRD1.N0 t'-.�� q2408
;SAN f3Ei'.NA#WINO,, CA 92408
USE OF PERMIT
c
,1~-il'.i35, PLAN 29. FNAs E" s".3+jbS N&'tPTi;a_W-E rAt.,ALL
PQ -01_ TW1* R.MtfCT1QT-4'f'C!•1°D AA4 b:xRROk $'kid' (YK AIULT1li',LE? PSWUANCE
OF SAME- P AN TYPE.
FEE. 10R-000-41$- �iti4.f1i9
KA2d GH;3C`t' . FE "tryry�C��3fr�T~da?�
aaC p�1/I'��E�
c�l/.il td•�,1�'IMAi. 6•.[' •., A.V.!"\71�V"421"V4'l. •.DRif.t)Q
-
"rd.1i;�"" `AIRA�:;AlE >r,. iQ.t iifi i-1
t'1 Uivf13f.wl Fall1QT 0(3t� �J'` 9-0�iU 5f 15 i; s S
S RInfdf, N4,0VON FEE. TSEA f $10,64
O ai/�j�}�iG iT ,f� I.b.1 Q l *%v 3� �L00- �i'miCt,Sltl'
A3 't' 64 P(Jf. iJC FrLAC ES. - RES -Vi", '1f}E-0011--255•di00 .. :"$14:99
PLAN
[ry�C1-}}iFc}n<*
^fJ..P ;Ib.9:.
RECEIPT
DATE
BYj{/�C
Y� -
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Z,'2. -t3® h0
Ducts
Slab Grade
2 - r O -@Q
Return Air
Steel
Z - Z - 66 K 14
Combustion Air
Roof Deck
-!
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
- t _Q
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
Final
_
Final 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
i, -Z -04
Heater Final
Water Piping
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
(p ,Z ,._0 0
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: