SFD (9907-372)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that], 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
3725a (}2iaJ2(ii
Date �-� Signature of Contractor
-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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).
( ) '1, as owner of. the property, am exclusively contracting with licensed
contractors to construct the -project (Sec. 7044, Business & Professionals
'Code); -
(j ' 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. •
(v "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:
Carver Policy No:
(This section need not be completed if the permit valuation is for $100.00 or less).
( )
1 certify that in the. performance'•of the work for which this permit is issued,
1 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 shall forthwith comply with'those sions.
Dat' '�
e:oApplicant
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 of this applicaton agrees to,.& shall, indemnify
ml
& `hold haress 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 inspection purposes."
Signature (Owner/Agent) Date
BUILDINGPERMIT PERMIT" `.
DTE r VALUATION�tKy)t LOT _ TRACT
SAN 0 V2,000
JOB SITE
'ADDRESS 7� liil�Ell.l� ��C��Fw�9 6�8iS�l�l! �Vrtllt���
APNa1«�d��-Q�
OWNER s _.
CONTRACTOR/ DESIGNER/ ENGINEER --
S
IAC CAT L,1.1JS RES1IJwN':'fmC01jsT',.,1NC.
5 PAlRK mjj Z 1 srj,- 400
5 PiR i'i,AZA, S1:J11TE 400
1i�V.tt'r111 CA 92614
IRVINE C -:A 92614 .
CRL## - :5072
'
USE OF PERMIT
Sli`GLF CAM[LY DWEiFLJ,117fC,
SFLD - LOT 65 PLAN 1R MIT DOES WOT IN(1.un%.tji.00K WAIL OR
1?OOL.95%11LAN C fEXX 1d11)1aCTl:0N APYL" FOP, MUL'1`WI.11.'•
SUI31ut17"F.AS..
.t.=.00 SF
POR.C.:�0r+.`I o 123.00 9F
(fARAQWC-AR110.it<i.' 441.003F
1,17,1 IM"aEb► i a D C08T OF CtwiRiS'iR".,.t>C-". ON.
108,248.%
MUM IT ME SUMMARY
C0N811kUC ON FEB 101-000-4111-000 W1.00
�
MAN CHECK EFTE $140.50
ME t, a^lANIGAS. r '13 1rJ1 C�U �'�a 4}OQ $66.50
OX GTRICA fES i01.-00.4'20-000 $120.43
PLUMKNO FM l.Ol -000-114-000` S142.00
g=rR_t>Nc t °fp N ryEI '-tt1iS1O )nl-(rn�n 4) 1j�3 x10.82
t 44
Ol:.ADMG FrT;
.Fit:l' liflT1BLIC:.KACES-REiiX, ` 01 -OI -255-0 0
DIEV ELOPE 2 .I.M.1"AiCT FEE
J>
�#
a
`i TB-. [`tY7~ I, ("ON .�`!b.UCII(?N AND F .AN C.H0,'C.
LESS PRE l� � �
.�
-# 0rFA8..i'E;1[i1V3:17 T! l'.S ME NOW
$31 0098,87
_ X
e. ..
RECEIPT
DATE
BY/' `' •t4�. { F -
1.
DATE F ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
A
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air _
Steel
Combustion Air
Roof Deck
M p —
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation47—
/ :SeVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—goo-/�_E
'
_� ��O
Final
Final 6 Z
BLOCKWAL 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
j
—p Z
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring v ...
Low Vottage Wiring
Futures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) .2 > 0 L
COMMENTS:
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