SFD (9912-057)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
j ' + tW - BG2r28.�itit
Signature of Contractor B
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 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 bq 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
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.
(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 provisionsofSection 3700 of the Labor
Code, I shall forthwith comply with those provis�onsl
Date: - Applicants 2J�
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 pursuant to
any permit issued as a result.of4his 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 orwork for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct,) agree to comply with all City, and State laws relating to the building
construction, arfd hereby authorize representatives of this City to enter upon
theabove-mentioned property for inspe
ction purposes. -
7
dSignature (Owner/Agent) - Date
BUILDING PERMIT PERMIT# .
DATE VALUATION $1,10,154.60 LOT TRACT 1 8 835-'3
/ +{
JOB SITE 3�x .�FUR"
APN -n
%i4�yADDRMf.
r•�
OWNER
CONTRACTOR
JqiGEM*'. L,' ",;,I,OP*,E--i CORP
y/DESIGNER {/ENGINEER
i��..hf.L�1.11-.11..Ji`'1.(7 i✓ i1V ll.�L{l'k ,�.r 1�,1 �,/TiWt%r
78-615 NAPLES, DRWE
78615 ivA_PLFS DR
LA QUiKrk CA.' 92253
LA QU:1NTA C.A. 92253
f766)777-02222 C13)e{! 57.58
USE OF PERMIT
Sril-nl Aiv �f:ui�i CiT ll,t'} fcMii 1 OES NOT INC' U!DE.i?lri A -.K. WALLS GR
iJ Fa.S.• 3 �.y�1�i:J 1�.\ll��.�J YOv l�.,M�l�%.�i� li' .
PORCiClI?/ LTIO '110.00 8 .
Ci13ACAC`It:.`it:.A32P01,,Cf 471AKi SF
•
1
C�.L�,i 1t .3.l.YAYt'l�1R L,a,➢ C"OST OF
A 30gt;0F
PE, KNUT FER, SUMMARY
(1(Aq.11111(UC."11.0Nk 'E 1.01-000-418-000 S743.00
KAN 014rX1K -F9.15, .101-000-419,318 $(i! R,.74
NI CH PIdA,L'1s .C1A-QC0-721,.•10100 S6(),01
2i.f?,k_1•RJ ALFEL iox-000-42"00 1134:92
Pf,*U� BING FE8 101-000-419-000 $140.75
"'IRt?Nc a,�f7'rtnnt f Ef.. lr ?Sf17 'i4�-0t t1 -M -(1!)i► 13.02
GIZADxr-e 1'f �l 10:1-000-423-0()0 $20.00
ti►1;1/�£%leiii+llt X3.1%lit"'` 1:'s:ly S,'1.,�3()7.ftU
� .. ,
Altl laN PLI.IlLiC PLACES - R611- 701 ()()Q ZSS-U!)0 S75.`39
'
Z'. OMFOR1. fC710N AIN1_) .PJ KN CIM CX.
t�-J.•%�`,%•�S4
LESS 1217E -tit M') TIES
$0.00
TOTAL #.'E1?i!/6Y 2' Y :MRS '!)UE NOW
53,717.32,
RECEIPT
DATE
DAItFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
Slab Grade
��
Ducts
Return Air
Steel
Combustion Air
Roof Deck
— Q–p0
Exhaust Fans
O.K. to Wrap
-tea
F.A.U.
Framing
pv
Compressor
Insulation
-- Bo
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-LG-
Final
Final 0_A0
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 I
I
Gas Piping.
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
000,
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 000
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)
COMMENTS: