0207-058 (BLDG)i rnereuy alunn unuer penany ul perjury tnat i am ucensed under provisions of
Chapter 8 (commencing with Section 7000) of Division 3 of the Business and
professionals Code, and my.Llcense Is in full force and effect. ,
LII?ense ar Lie. Class Imo. Date
7331.32 B 3/32/f:i
Dater
Signature of Contractor j
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from .the. Contractor's
License, Lavi.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 structure is not intended or offered for
sale (Sec. 7044, Business Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & .Professionals
Code).
O Lam 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 Labor Code, for the
pe rmance of the work for which this permit Is issued.
,) I have, and will maintain workers' compensation Insurance, as required by
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:
Carder 9TATEFWD Policy No. 04601UNITt)M13
(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 the
workers' compensation laws of California, and agree that If I should become
subject to the workers.' compensation provisions of Section r37of the Labor
Code, I sh Ito with comply with tf'oselaio' s
Date: �' Applicants + ,
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
fora permitsubject 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 benefit work Is,performed under or pursuant to
any permit Issued as a result of this applicator agrees So, &shall, Indemnify
& hold harmless the City of La Quinta, Its officers, agents and employees.
Z. Any permit Issued. as a result of this application becomes null and vold 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 ceRHy that.l 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 Ingpoctlorl purposes.
Signature (OwnedAgent)/Vh �� Date !
OUILU114U rrh1V11l oao���
DATE /� / VAWATION LOT TRACT
-'
JOBRESITE /1�1(
ADDRE39 Q S
AP.N
.
-
'OWNER
CONTRACTOR/DESIGNER/EN (NEER
1i�G.A VTtia�i' W1fiiT1A.i. AI J.
Dn,MAR VAf:IKC C ILRALGUNTB
P -Q, BOX I OR)
2533 SCAM C'C?AS'I' IIIGMAY M, 230
LA QIIMTA CA 02233
VARI FF $Y TIR RRA CA 92007
(?60)3(A-9300 Cf'l10 58'23
USE OF PERMIT
c31�1 13i.T.t� d?�NO
tt1.[i4%. P: 1110 t*7, 84.693, 90.64 80.671; VO1.UNTARY
OTRUCTUR.AL MODIMCATIO NS
VALUATION aQt1A4:00 I.S
NOMA71D C0r3'x OF CClnyl'Etuenon
20.000.00
I111twi' it a 8i1At[M AR'Y
COMI'RUCTION FEE • 7, 101-000-4118400 3�0"�,1►0
ST1101,10 MOTION 1RW. - R Z4 101-000-241-000=lla.tf0
CITY OF LAQUINTA
FINANCEDEPT.
008-TOTAi , t^,OMBTRUC'IZON AND PLM C MCR � '
.: $209:00
IMS 1%H-PAJD I �.fi
$0;,00
TOTS. ERMr FM DUE HOW
4" .av
RECEIPT
DATE
B
DATE FI ALE D
INSPE
yi
z,1
INSPECTION RECORD
OPERATION 1 DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Finalvq.-Aqv-POOLS
- SPAS
BLOCKWALL APPROV LS
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 neater Final
Wa'.e, Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
I
O.K. for Finish Plaster
Sewer Lateral
Poo! Cove!
Sewer Connection
Encapsulation
Gas P icing
Gas Test
� Final
I !
COMMENTS:
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