0308-097 (SFD)50540 Los Verdes Way
0308-097
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
7 769 B 04130125
Date 2,6/0 Signature of Contractoi9 !">zz
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).
() I am exempt und&,Section , B&P.C. for this reason
Date Signature of Owner
WORKERS. 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.
(d+ ) 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 L1D'RR.T'1' MUTUA1, F Policy No. WA24DO04-723012Tr
(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 s all f • rthwith comply wit those p ovisioras.
Date: `?, `' 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, 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 pursuafn
any permit issued as a result of this applicaton agrees to, & shall, indem
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of permit, or cessation of work for 180 days will subject permit to cancellaI certify that I have read this application and state that the above informaticorrect. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for insp ction purposes.
r
Signature (Owner/Agent) _/ " Date
I
BUILDING PERMIT PERMIT#
owa-097
DATE VALUATION d LOT TRACT
89. 3(,57
JOB SITE. Po , r
ADDRESS o N_540.1o0.F t;WAy
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TOLE, r3I='0771=7199,
i Lx P1 O '[T i Th c
73.121 TTtFD WARINQ #100
73-121 FIRED WARING #100
1?,ATM'DRE ' ?,RT Off. 92260
PALM D&SE tiT CA 92260
(760)674.9699 C'.E 141 38311
USE OF PERMIT
o*ffl(ILE FAALf1 Y DWL X1140
SFD , LOT -99, SEMONA,& PMMIT DOES NOT INCLUDE BLOCK
WALLS, P004 SPA OR DRIVEWAY APPROACH, 75% REDUCTION TO
PLAN CHEC.r PEE DUZ TO MUL;' IDLE ISSUANCE OF SAME PLAN TYPE
CUSTOM C;ONSTRUC°TION 2,800.00 OF
PORCH/PATIO 273.00 SF
0ARA(WC1A PORT 510,00 SF
ES- MT•1 COST 01F CONSTRXICITON
233,73.3.50
PF"/Lli'1.1T.E ffMVI&ARY
CONSTRUCTION PEE 101.000-411€-000 t1,f03,50
PLA14 CHECK F`EE 101-000-439-3111 vrioo
MECHANICA1,.F R 101.000.9.21-000 5111.50
E•L,E,CTRiCAL r E . 101-000-420-000 $16630
PLUMRINO FwE , 101.000-419.000 $131,00
STRO1VC3MOTION FE.F. • RP010' 01-000-•241-000 $23.37
ORADINO HE 101.000.423,000 $15A
1'iEl'ELOPtR 1MP.A.CT ?FE' $7,+403.00
ART IN PUBIX PLACES --RESM 270.000.445-000 8X33 -
Sl,}T3JPOTAT,COl'hIS3.'r•.l`I('°1TOAtAND :133:.WCHFICK
$4•_324.90
n LF.y 0 1'Pk? PAID FF -ES
$0.00
;FINNEP 2 6 2003
Y OF LA QUINYA
;.
ANCE DEPT.A/,
RECEIPT
DATE
BY 1
D FILLED
I SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.to
Framing
Compressor
Insulation
✓
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
Final
BLOCKWA
L APPRO
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 PPROVALS
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
Final
Utility Notice (Gas)
ELECTRIC#L
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)
APPRO ALS
COMMENTS: