9812-225 (SFD)LICENSED CONTRACTOR DECLARATION I-
I hereby affirmunder penalty of perjury that I am licensed unrder 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. -kk,
License # Lic. Class = Exp. Date
tillc� 4t,
ate f/! Signature of Contractor
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 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).
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.
(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 t e rovisions.
,pate: 4Z, dJp Applicant A 4�..
Warning: Failure to secure Work re s' Compensation coverage 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, indemnity
& 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.
Sig re (Owner/Agent) Date __ak.
i �J
r'
BUILDING PERMIT PERMIT
9812-275
DATE VALUATION S132412�.70 LOT 1154 TRACT 28545-'2
.ADDRESS 4 9- 25 AV ENI DA 19�5�.�+'T,ri. N
APN 63.1-374.02
OWNER
CONTRACTOR DESIGNER ENGINEER
K181 Livff) u :,AptR o,,-
!
tSL tINO it rOR7LRp +ON
55-920 PGA 6LVD
55-520 Kit\ BLVD
LA LaUI NTA CA 92: 53
LA QUltdTA (FA 02253
(760)%A-7105 M301"
USE OF PERMIT
SINGLE FAry IL DWEL.L.T1 G
S.1:D, LOT## 64, PLAN 2A. IyMAIT DOES NOT TNi LURE 41LOCK WALL
C:)it I�CiC)L. 1'1:AN t:�t'�j(;li 1•"EH 44EUUC.�Ia 75y� H'(,:)I'tA�.t:tLll'I,� I.SSUAI�!<:1;. t)F' .
SAW PLAN rYPH.
CUS-10ty! CONSTRU(ri;ON 1,6`14.1 'SF
f'OdZO,FIIf'A[IC)'iS7.()t7 S�' i'.
EE,Tf MATED U -MT O;." CONST RUCIIONI
14AMITFEE SUMMARY
Ci)Pf'ITRUC'FION FEE 101-000-418-000 $755.00
t;,
.P4 • NN (7HF0 ;. f: Hr. 1014X)0-419-3 19 WA) 21
NIL:CIIAUNICAL FU7 101-000-421-000 598.50
E1.i;C".PECI+:;rll. b� iski 101.-Cfl}0-�12f1-L�0 $ l3 (.tiy
.
PLU.MBINO FEE .101-000-419.000 $174,54)
!�'P9�CYN M1 ►1'IC1W $13.25
GR AI:t: NTN r'f t, 101-000-1123-000 520.ot)
st,fFRA.1("iWC1'UTtU- fEE .125-000-443-342 52,9:+a.Io
ART IN PUBLIC., PLACES - KESIC 701-W0-255-000 $81.23
4
LESS PRE-P.I T) FEES
$0.00
`I'()7"Al, MCNlli F !1 FES KIENOW
$4,367.88
RECEIPT
DATE
BY r "S-
DATE FINALED
INSPECTOR 7�1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
. MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Z
Ducts
Slab Grade
Return Air'
Steel
Combustion Air
Roof Deck
<'
Exhaust Fans
O.K to Wrap
_
F.A.U.
Framing
Compressor
Insulation
- UV
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
— G
Drywall - Int. Lath
Final
Final el,
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond y
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
S Lateral
Pool Cover
Connection
Encapsulation
Piping
Gas Test
_ �J
Appliances
Final
Final /_ cw
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 GU
Utility Notice (Perm)
COMMENTS: