SFD (9907-009)LICENSED CONTRACTOR DECLARATION
-'0) = ` 1 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
W=.: Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
t-- QLO
I`
Z � rl-- ate Z�,, " � Signature of Contractor„ , - a
Orr �.,.,,,ti..�.....^.....
r- H o OWNER -BUILDER DECLARATION
W a I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following -reason:
Z ( ) 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).
ce) () I am exempt under Section B&P.C. for this reason
Ln
N Date Signature of Owner
0N
U Q 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 Ito 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
Se tion 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).
O 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 agre Alla' f'I`'should become
subject to the workers' compensation provisions of Section 37, 0 of the Labor
Code, I shall forthwith comply with those provisions.
Date: '7/, 4V sr Applicant ( ��
VWarning: Failure to secure Workers' Compejsation 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 ipsve tion purposes.
Si�ature (Owner/Agent) D at A6, / '•�
wr I
BUILDING PERMIT PERMIT#
"U7 4k3")
DATE VALUATIONLOT TRACT
S:3g1,3f�8.3f9 49 289 12
JOB SITE t _
ADDRESS . ' 9415 1,i'�ONTANA �(X
APN
® -210-007
OWNER
CONTRACTOR /DESIGNER /ENGINEER
,
TDJaLSEWI yE }.)1"I&Iiy
SPARKS `ONSiZkgO
PO BOX 1716 }
79-295 RANCRO LA QUINTA DR.
LAL Qf..l9NEA CA. 92253
L'A (Dt f1NrJ A CA, 0225.3
f 7177{117 � 1-1,9�.t C• UO 2990
USE OF PERMIT
'SINGLE r.M.iL Y DWELLING
:SM -LOT 49 ;P ANN-:0MMrf :1307#-S''NOT 1NCL10H BLOCK WALL
1312 r4Ci0"L: 7' 1'Lrll�j N3.'ilrC: 'ETA itt i31J'lE ftf113%Oli EviUl i:i':f3?i
I:SSUA'I` a, OR SANG, PLANT PE.
Ct f s"rotm CmnT1 Ui rro`i 4,2Z,00T
1?Cj til r1 `If3 �1 :4. ` n2.00 SF
0E4RA.Gf ICAIWOk'.!' "ls0,t)U sF
ArEo C40S T' 0.F CONS y` :Uirw'fJs3F�T
PERr,rrM k'RJlf; SUMtINIMtY
t;0Td `Cb�IJC"T'1ON FEE 101.000-43.84M $1,521:50
P,T.; IN ("HEM FSM 103 ,WQ-439-3113
MEiCOPWIiCAir:Fl;; s x,136,50
EL1r`.C.` RIC'AL FE8 • 10'1 4l4 -zat0-0106 $2463-4
Iji 11Mk�1N� 2 f 101 -000.4.19 -WO S2105.00
;a'g'12ON0,MY1710 Fri F, R]"3SID. 1014100-241-000 "5,14.
GRA1" NT% FG6 101-000-423.000 $20.00
i Nl RtA6q";itUC'r0R111 FEE, 225-007-443-342 S6,00o,i
A,RTfN P1JBL:1C; PLAOFS-'RE-SID 701 -OW-2-55-000 $628.47
SUB -TOTAL CON S1'RUO'1'ION .t1:ND PLAN CJ:f ECK
$9,102,,
Lr,SS RRk-PA ID FENS
MOD
T()'> AL YERMI"T VCHIN UE, NOW
3I
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
Rocf Deck
Exhaust Fans
0. K. to Wrap
�jej
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
c
Final
Final
BLOCKWALL APPROVALS
POOLS --SPAS
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
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
cd
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm)
COMMENTS:
Iq 00 l—' 2 -0 -OU At -'K