0004-047 LICENSED CONTRACTOR DECLARATION PERMIT# /
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
F'— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 0004-04^1 TRACT
N W Professionals Code,and my License is in full force and effect. �J) I 11ty)
$27,3W.00 29306
O =) ch License# Lic.Class Exp..Date
JOB SITE APN
1 67 0 4 13 07/31/20 ADDRESS 7960- FE 4$ -
i
Z Date ��'�. ^^ Signature Of ContraCtOr OWNER CONTRACTOR/DESIGNER/ENGINEER
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� H � OWN ER-BUILDER-D CLARATION TD DF..:1WJrD..EVFLOPMENT SPAWS CONSIRUM- ON
lV W I hereby affirm under penalty of perjury that I am exempt from the Contractor's PO BOX 1716 79-295 R NC", O L,A.Q•Cn..N'TADR.
~ U) License Law for the following reason: 1 LA QUINTA CA 92233 LA QUIN A. CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole 07760)771-1941 CBLA 2,99E
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals C#M40 AL BUD-DING
M Code). 1092 L.F. 81(11)CAR.DEN WALL•OR.CO STANDARD PER APPROVED
ul () I am exempt under Section , B&P.C.for this reason PLANS ONLY
N Date Signature of Owner
ON
Cn
d Q WORKER'S COMPENSATION DECLARATION
C:) z Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' b FT.WALL 1,092.00 LF
X w compensation, as provided for by Section 3700 of the Labor Code, for the
O J JQ performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier $TATE FUND Policy No.
ao 046-0007338 ES'IM.I+T. 17D COST OF C:ONS:CRUC.TION 2:7,31)0.00
�
C3 1P"WW.FEE SUARIARY
J (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FEE 101.000.418-000 $071,50
( ) 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 ofC alifor'n a and agree that-Hshould become
3 subject to the workers'compensation provisiocti
ns of Seon 3780 of the Labor
Code, I shall°forthwith comply with those provisions. (/
Date: In Applicant-
Warning:
pplicant Warning: Failure to secure Worke"rs'"C`pensation 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
Qrof 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 r
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 SUB-TOTAL OTAL CON rRUMION AND PLW CHWK $2%1.50
any permit issued as a result of this applicaton agrees to, &shall, indemnify I,LF..33 PRE-PATI?F. $0.00
& 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 •LOMAT,19MAIAW FEES DDE NOW 71
work is not commenced within 180 days from date of issuance of such .50
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 IIIIIIIIIIIIIIII�IIIIIIII
• correct. I agree to comply with all City,-.and State laws relating to the building 63
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned propertyfor inspection purposes. JJ
,// RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) { DateJ/ 0c9w-
i
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 i
Roof Deck Exhaust Fans
O.K.to Wrap F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.Q. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS Steel i
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
Appliances
Final
COMMENTS:
i
Final !
Utility Notice(Gas)
ELECTRICAL APPROVALS I
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Vott ige Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
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Final
Utility Notice(Perm)
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