0205-101 (RR)1 hereby affirm under penalty of perjury that I am licensed under provisions of
,Chapter 9•(commencing with Section 7000) of Division 3of the -Busine Business and -
Professionals Code, and my License is in full force and effect.
License # Lic. daiss Exp. Date -
Y
Date <" Signature of Contractor—
OWNER-BUILDER DECL4047HON...
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 Wbrk,*and the structure is not intended or offered for
^.sale (Sec. 7044, Business
siness & Professionals' Cocle).
( ) 1, as owner of the -:property, am exclusively contracting. With licensed
contractors to construct the project (Sec. 7044, Business & -Proies-sionals
Code).
O I am exempt under Section B&P.C.'for this reason
Date Signature of, Owner
---WORKER!S COMPENSATIONbECLARATION
I hereby affirm, under penalty of perjury one of the following declarations:
O Ckave and will maintain a *certificate of consent to self -insure for -workers'
compensation, as providedfor*h,thisby Se6tibn 3700 of the Labor -Code, for the
performance of tI have and fie work for whi which is issued
' : I
will maintain workers' compensation insurance, as required by
Section 3700.'of the Labor Code, for the performance of theworkfor which this
permit is. iskied."My Worke'rs' compensation Insurance carrier, & policy no. are:
..Garner Policy No.
T AVI
(Thip4s ection ne ed rlii be completed ifthe permit valuation is for $1 00.00 or less
z'l certify4hat'in the p6rform5nce of the'workfor which this permit is issued,
I shall not'eimploy any,person in -any manner so as to b6dome.-su�bje*ct to'the
workers' comp ensati6n']6w`s'.of Ca,lifoiiiia:',* and agree- --ikat-:if-i'sh6'uid'bedome
sU6j6'ct to th6 workers 'compensation'provis ions Or Section 3700, of the Labor
dodiil'I'-sh4ll forthwith comply `with; those. provisions.
J
Date � Applicant pp icant
Vkarnmg:_ Fai ure to secure WorkersObmpeinsation�.=V&rage is unlawful, and,
shall4u15j66tan employer to criminal penalti6s, anddiVil:.f ihd1s:iJp to* $1 ob , 000, in.
addition to the -.'cost ,of compensation, clamiges* as";
provided f or in Section 3706
of the Labor Code; 'interest and attorney'sfees.
IMPORTANT Applicati6n_is heriaby.,made to the Director -of Building and Safety
for a -permit subject to the conditions and, restrictions set forth on his
.application.,
1. Each ppr:soii upon.whose behalf this application is made & each person at
.whos6.request=and for whose benefit work is performed under or pursuant
nt to
any.permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold ' charmless the City of La Quinta, its officers, agents and employees.
2. Anf.,p'ehm'it issued as'a result of this application becomes null and void if
work is not commenced within -18 , 0 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
I Signature (Ow6er/Agent) Date'- i
BUILDING UILDING PERMIT
t A.
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS V-1,1917 0AK. tXIM.
APN
OWNER
CONTRACTOR DESIGNER EN (NEER
110"L 'WYST PJ1'.t.1[I))-.N'l'fA1 .
i N
USE OF PERMIT
'0 F)(,.X
R(A
INANCEDEPT
tM,T(Yl' N t 1:
JA -PA.J't.!.V*i-J1
0,4VIRi:
14),
RECEIPT
DATE
7
1BY
I DATE FIJN)7D
INSPECTOR
OPERATION
DATE INSPECTOR OPERATION
DATE I INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck �Q
Exhaust Fans
_
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
j Grills
Fireplace T.O.
Fans & Controls
Parry Wali Insulatio-�
Condensate Lines
Party Wall Firewa'!
Exterior Lath
Drywall - Int. Lath
{
t
Fina.'
Final
POOLS -SPAS
BLOC
PKIAIJ, L/ APPROVALES
i Steei
Set Backs _
-lectric 5on_d
Footings ;
—
;.Iain Drain
i Eond Bear
_.pprc�'a' to Ccvcr
__—
Ec:iipinent Lc--atien
t
t
underground Yto4 lest
Fina, i
"as Pi,,.r.,.
�V,,astr Lines i
— — E = r Fina".
Plumbing Tor: Out
Shower Paris
Sewer Lacs, a
-c Wlerl 3nreci;o .---
_.—a._N _ .--._—_____
_ _ _. _ .�._ ___. - - - -- ---
—• I
Gas ;'ipI„S v
— - - ---
L Gas Test
—
1 Appliances
Utii :y Notice (Gas;
—.i
E; ECTRI.,AL APPROVAL;
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring a
Fiar-- t
hair: Seriice �
` Sub Panels —
i Exterior Receptacles -—
G.F.I. --F-- —
--
-
Cmoke Detectors
Temp. Use of Power
r {na) --Y
Utility Notice (Perm)