0205-100 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of
-Chapter 9 (commencing, with Section 7606) of Division 3 of the Business and
Professionals Code, and my License is in full force,and effect.
Licen.se # Lic. Class Exp. Date
.o
;io
/bate. Signature of Contractor—
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Licensb Law for the following reason:.
( ) ' 1, as owner of the. property, or my employees with wages as their sole
compensation, will do - the work, a'nd'.the structure is not intended or offered.for
.sale (Sec. 7044, Business & Professionals Code).
1, as owner of the ;property, am exclusively contracting With licensed
contractors to construct the project - (Sec.,, 7044, Business &"Professionals
I am exempt uncler`Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm unicle"r",p6nalty '.of perjury one of the following -Aeclarations:
O I have ,arid- Will -maintain a certificate of consent to-se'lf-insure.-for '-workers'
compensaiion,..as p6vidbcl for -by Section 3700 of"the Labor Code, -,for the
S s
peftimiance of the orkAr wkic'h' thi permit issbed.
i'
1_ha.ve',�ncl will m ntain workers' compensation insurance, as required. by
Sec 3700 , of the: La bo'r' Cod'e'; ',f'q'r' the. performance 'of the work for . which this
permit,My woike'rs's• Compensation insurance carrier & polity no. are:-
Cirier' Policy No.
aIT11,11 A:) . ,
(This section ,need. ndt.be completed if the permit -valuation is'lof.11 00.00 or. less).
O 'I certify lhat*Jn. the, perforni anc6 of the4''ork for which t I his;permit is -issued,
-1 shall not employ anyin any manner so as to become subject,.to the
workers- compensation laws.l person_of Ca . lifornia, and
d agree that if l.should become
subject to the workers' compensation provisions or Sectioh 3700. of the Labor
Cod Ishall hal forthwith c6mply:with those, provisions.
Date:,17 - Applicant
Warning: Failure _to secure WorkersCompensation =age. -is unlawful and
shall subject an em-plio'y"er to criminal penalties and fines.up to, $100,000, in
,addition to the cost6f:-dompensation, damages as.provided for i6'Section 3706
of the Labor Code, interest and attorney's fees.,.:
IMPORTANT%Application is hereby made to the Directof of Building and.Safety
for,a permit subject -to'. -the conditions and' restrictions set':f6rth on his
application.
A. 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 perrM,"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 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
con�trU ction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
e.
HtHMI I N
.
BUILDING PERMIT
l;(10 .. .
DATE VALUATION LOT TRACT
JOB SITEAPN
ADDRESS 5Y-5-777
OWNER
CONTRACTOR/DESIGNER/EN INEER
t Wktil 0 3) W;•,,.A.LAJQ 1.11, HIA., 04(
Y
V PA!-, - PO NY ""0! 1 1- J %A`
JI.A Qr.
USE OF PERMIT
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TMAI. MeRN0.1' NOW
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RECEIPT
ATE
BY
IDA
INSPEJ
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATA I i INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS �
,
i Set Backs
Underground Ducts
Form & Footings
Ducts
i
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—
,4
Exhaust Fans
j O.K.:o Wrap
_
�
F.A.U.
` Framing
j
+
COmpfeSSOr
! ( I
insulation
Vents
1_
Firepiace P.L.
Grids
F,rep,ace T.Z;.
Fans & Controls
r Ps:ty Vali Insulation
Condensate Lines
1 R
j�darty Wall Firewall
HI -merior Lath
!
1
! 'Jryv?" nt. Latnfi-
1—.—_
iFinal
POOLS Z�!7�AS
BL OC-WlALL
APPROVA S
—
---- —
.Mee!
�.�`-E' 8,-iLkS ,----tel–
-
.—Electric
Main Dra:n
Aporcva! :;ove,
--- —
L----
—
}
Unde,ground E lecm---
I
IUn
-ergrM1::d ?lbu -i es'.
j
Eln2i
—
I
-- --
Baa P10;1--.
_ _ —-1
f�LUIt��; G APPI�OV/AL,"a`T"`-
'T`.
>^Jasta Lcrr =
c
tl _ — —
-• - — ----- --
Pi . ,ng Top Out
`q •ccs
=-----
ger Pans
--
_
--
'c
--- -- —1
Sewer onrn..[:or,
r`>a .:•gin
—
—... _---. ,—._ �— . - ___.—__-_
'
- __—.—.
as 7 cst
_. .�
---;—_. _ .--------
P _;,li2nccs
�
------�--•— —
.. _
I c Ana,
t (Ailily Nolte (Gas)
`
�_—
ELECTRICAL APPROVALS
I
-- --
--_�
Ten, p. Power Pole
�Uncierground
— -- ----
Ccndu"
Roi�q�n Wir,ir,
— —T—
Low Voltage Wiring
•—�-----
i Fixiures
-- —
► — _
__-�
Niair. Service
i -
--�
--
Sub Panels
r-xenor Racept3 :le=
—;
—�—
I ;rnoke De'Lc:tors
, emp use of Power
—— —_—�
�Final
Utiiity Notice (Perm)