SFD (9907-030)LICENSED CONTRACTOR DECLARATION
l hereby affirm under penalty of perjury that 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 xp; ate
�7�«����• i3 �1.9x115r:
mat /� �dZ Signature of Cont actor
OWNER -BUILDER CLARATION
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 isnot 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.
(VJ 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.
:111IMCV1?.!J
(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 Ihat'if should become
subject to the yorkers' compensation provisions of.•Section 3700 of the Labor`
Code, Sll f6R With comply with those provisions-,
ate: Applicant •--"�
Warning: Failure to secure Workers' Coirpesltlon coverage is unlawful apd
shall subject an employer to criminal penalties and civil fines up to $100,000,f in
addition•to the cost of compensation, damages as provided for in Section 3,706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions,,.and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
i Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to'enter upon,
the`above-mentioned"prope[ty f r inspection purposes. /
VSignature (Owner/`A'gent)' t/ Da Z
BUILDING PERMIT PERMITN
DATE VALUATION LOT TRACT
JOB SITE'_
APN
ADDRESS.,y7-;Fr75!1-.�Y1�,N.ANA@'4A
6494MG67
OWNER
CONTRACTOR/DESIGNER/ENGINEER
.
POP 1716
int. -2 S RAMC HO LA QWNT'A DR.
1, A. Q0.fltrl -A. CA y'22D
Lel. QUliIi'9':A CA 512253
CFO 71-1.941 fi)Oj,# 2996
USE OF PERMIT f
SINOY1.1E, d?/ MLL,Y i) VE L LINO
SFO , LOT '70 PLAN Vit;.; - Pih.�tiNTD iE.,S NOT iNCLUD BLOM WWI
ox t0c)L. enyb 1'l`.AN (;1i1>tw,`1? FEE f.tWXY-1T1QN ;F0R R-IULl°1 iOIX
iS:itlAty�"G 'R :5JlA1p !'L'li4''i'�"PC `
f
CUSTvfvt C014MY iF(MON 4.243.0 SF
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r
0ARAC4l1!( ilRl10iitT 7:10:00 SIF
1
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JA AL AA'' NY akJ E +,:rd9! �..CXv MY MON.
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$�. f+T,�rty
j q j��9 �a SUMMARY
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.
C0 -K8 T.RCtf- r10I•bFE:fa 1411 -600418 -OW 51, 521.50
PILIAN 0"E K" FEE $308,71
INT.1011ANl.C:'u, FEE 10 x -W0421 .1000 $136610
ix -u itSs. m.1'cx 1411-0011-d Ofl . S24631
PUTA 1.N0 FES 1014)00419 -OW 5205.00
S t L2t�1Vf i M.Cyl CLOW l RC�?Q 'I0 J -000»241 -1K -)(i S35.14
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�[S�lFd4!'[573-,RV\..1 URE FEE 225-000-44-A-342 86., f'1�U0
ART ]N PUBLIC PLACES - RESIC 701-000-2,' 5+ 1000 $67,11,47
�:jl-'1a7T=9 f HC l . iC ??(1i`vt A T'i� Pfi AN (moi F�';
4�wf1 .05
.•.:. 1:1 I�3tcr'T"1'a1: 1??a"
1$0.00
Ift
TOTAL PE* Mff 3"CIMS 01M. NOW
x9,102.05
00,
RECEIPT
BY
DATE FINALED
INSPECTOR
I NSPECTION 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
O.K. to Wrap
Qpf
F.A.U. '
Framing, -
cfJ
Compressor
Insulation
Vents
Fireplace P.L..
Grills
Fireplace T.O.
Fans & Controls
Parts Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shcwer Pans .
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
—
Appliances
Final
COMMENTS:
Final
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 (Perm)