SFD (9907-007)LICENSED CONTRACTOR DECLARATION
I' 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 Exp. Date
/" /✓Date � / Signature of Contracctto . l
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).
( ) I, as owner of the property, am exclusively contracting' with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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,'foF 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 ti+on 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.
i`t's MHutu) 014"007333
(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 agreefthat if I Should. become
.subject to the workers' compensation provisions of�Section 3700, of the Labor
Code,•I sh II forthwith comply with those p ovisions.
Date: &,/`9`5 Applicant � - ---
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall'subject an employer to criminal penalties and civil fines up to $100,000, iti
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 he�eby�authorize-representatives of this City to enter upon
the above-mentioned pro erty o, inspe-Ction pu .poses.
/ignature (Ownei/Agent Date!/—/,-,- f . ,-
BUILDING PERMIT PERMIT#
.. 9¢)f)7 -9)i17
DATE VALUATION LOT TRACT
47
JOB SI
ADDRESS
4> t1@A;CA9/-{fi:/
564 !i'1i.JIVYE`9.NkW�V
APN _
.OWNER.
CONTRACTOR/DESIGNER/ENGINEER
�
r
79 295 P,11iNCiiO LA QUiNTiA j3R,
f..A, QCJ. NrCA CA 93 253
LA QUINA CA 9725-
i
(76()1771-1941. C;.C3sA 2096
USE OF PERMIT [ +
SF? -LOT 47 PLAN A43 •• PI AKA T DOVS W011 INCLUM, BLOCi+ WALL
0K 1'(,301.. 75°je DILA CHFC:,.K FEE It.FD(Y(,'110.N*• -G.R, MLJLI'i' iPLE
ISSit:MIUM OR SAME PLAN WK.
CUSTOxioms'muC.mfoly 4,243,00 sr.
Pf9ROf-01'dv.T10 t ' .52 2,00 8f,
i,sA[2t1C1 lL:Al2iDi)It'!.' 71o.00 `s'!.''
VSTIMAT LSA COST OF CONSTRUCTION
351,M30
P:ERiQ11T 1< EF, SUMMARY '
E`°0NVrRU TI[Olkf'FRE 101-000-418v 000 S I. y? 1. so
PtANC',W.-fir it
. SS.�lVJti
vCNANICAL il13 101-0qn-421<'00
FLLC.''OUCA ; F8E 101A00-420-000 $246.71
PL1:fAti1311tiIC3.,FFE 101-000419-0W $205.00
41`R.()j�f!? Ar9fl'rf€)Af t i F nF3Kfl) 101-Of_±4-24 -(.h?t)
Ca \1')1NGFEE 1,01,-£1 0-123=000 $20.00
fNF'i2A,ti',t`1t:T1CIFU 3.rE1, 27.5-000-443-342 S6,0W.W
t _R 1`'LW PVI3LI.0 Pf.ACES - PC, SID 701,000- 2.55,000 5628.47
54X13=1 CY ' I, C•C Al "l' AJC .l'f)N ANDPLAN C� 4EC,F:
LESS.. PP.3 —PAID .FEES
A.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 10-
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade —
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap e„
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
Final
Final
BLOCKWALL APPROVALS
SPAS
POOLS:SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines L -
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 P,ping
Gas Test
Appliances
Final
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 C4 Gv
Utility Notice (Perm)
COMMENTS:
06 t,4 -J