9812-223 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of%perjurythat 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
� e4763t6 rr 413tuiJU
2iate % � Signature of Contractor-
OWNER -BUILDER DECL,ARATIO -
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 contracting with licensed
contractors to construct the project (Sec. 7044, Business &; Professionals
Code).
() 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 Labor Code, 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.
Z;UR1K"114INSUR AlXiE WMIl: "Al507
(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 3700 of the Labor
Code, I shall forthwith comply with those provisioms•.
Date: Applicant AW — N rtY
Warning: Failure to secure Workers' Come sation'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 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 permit 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
•' r
� 'T
�ature (Owner/Agent) j""' � � ® � .� - Date
i
PERMIT#
BUILDING
PERMIT
'
DATE VALUATION LOT 67 TRACT 28.545-2JOB
SiTt'
ADDRESS of 49-"S A��Ttt4J�J.MA ORRECONN
APN 6SI-370-022 .
OWNER
CONTRACTOR/DESIGNER/ENGINEER
KSIL LAND ff CORPOKAIION
;GSI.. LAND 41 CORf'C)it.A'('1ON
:55-920 PGA .r IND
55-920 PGA .BLVD
LA QU[NVA. CA. 92253
LA QUtiv'cA CA 9225:3
(7c►opm 71(id, 0-13LO 5323 .
USE OF PERMIT
SNGLEF^ -W, ILL DkV LLNG
SF0, L0`0 62, PLAN 213. PRP,c U T' DOLS NOT 124CL DE, BL.Ck " WALL
CUSTOIN,. CONSTRUCTION 1,6774M SF
PORCH/PATIO) 157,008F
PERMIT FE 9 SUMMARY
AR
C ONVI'RUC ION FEE 101-000-418-000
P AN ('FT k—K V r -F, it 0 i - 011-4:3V-7 i 8 S11140 IRS
NIZ, 0 4ANICAL FEC 101.000-1112. 1-000 S98,50
E Ei:!°E2ICAL FFAI, Iol•-+JO(1-X20-000 S131.09
1ILtdfvtk3lNG FEE 401-000-4194M $174,St)
�r't'f2(�I�fCi MC) (Ptltd dre F . F�F:S►'!� I f)1- 1t;1-241-fIm
GRADING Fri; 101 -OM -123-000
IM"11,AS titi1+;.:'t'URPs FEV" 22.5-000-443-342 S2,9M.16
AWF 1N Ptff51 JC: PL,ACTS - R SLC 701-000-25540) $81.23
8I IH_'r(Y1'AL t:ONS RIX71. ON AND PI..AN (''HECK
$2
LESS PRE. -PAID FEES
�O.ftQ
I'MAL PERMIT FEE -44 0lilC .iN0%-V
54,848-52-
RECEIPT
DATE
BY/ "
DATE FINALED
INSPECTOR
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
0.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
Gd
Final
Final I 'T- 2 err c_
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
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
cw-
Appliances
Final
Final 7 - Gt/
Utility Notice (Gas) C-</
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 .- cc d�
Utility Notice (Perm)
COMMENTS: