01-0081 (BLDG)s�
R , 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 ,
'Date ' � t,(7h/ ..Signature of. Contractor(/�-.`%/•f
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 ownerof 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 (Seca 7044, Business & Professionals Code).
( ) I, as owner of the ,property, am exclusivelycontracting with licensed y.
contractors to -'construct 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 and will maintain a certificate of consent to self -insure for workers'
.compensation, as provided for by Section 3.700 of -the Labor Code, for the
performance of the work for which this permit is issued., a
( 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 1' Policy No.
T6 tl..l. l:-;''+..TN'y�J • .'. t • , �aFKtn.7 f^�,i
r (This section need not be completed if the,permit valuation is for $1.00.00 or less).
O I certify that in the perforrriance 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 Se6tioriy3700 of the Labor
C6de, I shall forthwith comply with those provisions.' .
16ate: //"/V 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
applicatior% Y -
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 applicator 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,commenc6d 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,f 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
g
/bove-mentioned property�,for ,inspection purposes.
'S nature (Owner/Agent) * �^�'Date%
PERMIT• :PERMIT" 4'
,BUILDING
DATE' fa I.�: �.al �i VALUATION+ 901) LOT .TRACT k{��i'�, �!2`T
. _.
ADDRESS .S�i-��l! Ikri�!d�l�yr�P L�:.C�l�` - JOB SITE
APN'
+ a
OWNER
CONTRACTOR / DESIGNER / ENGINEER
>�r..l�.t:C)N..da�.t�+,Y�'.,:SgZS _
IY•�.i,, Y.3,CduftJ.lYJ�1.�.�,�..ti ..
743 S:,'WVREN CD
'74.5 S. MARENGO
w C:d1 9.111
RA -.ADEM i CA cr1 06, ,
(620)584-49_44 C,.RI't, 52 4 _
USE OF PERMIT
GENIPRAL1:1I).f.l.D.tNG
t
20 L,V , Y XVR000,f•I'C MON FEENiCE WIN x ICY" SQ. a?#l. Ae)—L eu AT � 3
it O.U; T H.143 -H k.R KV GATE ;eS h It .1i'i:3R W116" -W, P:Il'..A1Si f.;R.` .
(WOOD N; ENG63 rt C:L'JT)A2D WITH a%f? 9N3 -ted AIT) K
�:
i`
MARY
r
%jB-!MAL c_",014S?'RU`7€C';N.f1ND PL-A5441,��•Ti�iE �•,
$3
LESS t E1R0,00
10 }
1'0'rAL A°CRAl'9T $i'fi+� , S' Dtb.t`1?;NO4i'4'
�;fi71112..
RECEIPT .
DATE,
BY'
Dq� IN E
INSPECTOR.
a r�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs S'
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final -
Gas Piping
PLUMBING AP ROVALS
Gas Test
Electric Final ,
Waste Lines
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
Appliances
Final
COMMENTS:
r
x
4
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)
new 5' wood fence 175
DRESSING
. I 11 sqa
existing 6' block wall I -- --
MASTER BAT EDROOM STUDY
A RE -INSPECTION FEE Of $30 98 egfl I23 sqR 153 sqR
WILL BE CHARGEU iF THE APPROVED
i PLANS AND JOB CAR ARE NOT ON
I 11
THE SITE FOR. A SCN�ED�lLED I MASTERBDRM
280 sq fl I�..�'
II} p II O N BATT
iSf EGTIviY. BATH 50 sq
rr
new 5' wood fence -751 I OFe ET
CI OF
QUIiVTA
BUILDI G & AND DEPT.
i AP ROV
FOR CO TRllGTL0
DATE +/Jero . Y L,f'�