SFD (0111-174)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.
Licenste�# as p Liic... Class Exp. Date
s
Date ° '7;%'rr Signature of Contractor
77
OWNER -BUILDER DECLARATION j
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:
O 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.
( ) 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 ISTATA F:P;ND Policy No. 046-0001M
(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' compensat!pn laws of Califor,,1lia;Ian"d ag ree that if I shout- become
subject to the6workers' compensation provisions df Section 370.0 of;th Labor
Code, I shall!forthw�h comply wittythose provisions ,J'
Date:; I. V Liv d Applicant i
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
& hold harmless the City of La Quints, 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 authorizee representatives of this City to enter upon
1�1111
the above-mentioned property`for Inspection pa ses ,., ' "
Date,
Signature (Owner/Agent), ~b'r �' �
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 11-174 TRACT
4!"�� 631,'3' 7 29457-2
e : '� /'• .. e t
JOB SITE
APN
ADDRESS 7"16 M.�Z4ii�..OT'ST 1W1.W. KA .b
.649 -2.1040.2
OWNER
CONTRACTOR /DESIGNER/ EN INEER
TD DU OT'DEVEMOPMENT
SPARKS CONVIRUC1101W
1?C9 BOX 3716
79-295 nmcuoLJiQYSNTADR.
LA C,3,`Cf;Clto R;A CA 92 2.5 3
:f.A QUW-TA, C.A. 9 2 2 5 3
(760)771-1941 Miff 2996
USE OF PERMIT
y� qx�'�•;+` �,�,g�+�
lv.tS ay..:�:, 17JJ IAI :Y D V'7d:al.JuSF:V ,
V11 LOT 7 1?1,AN Sa. Pp•RMIT P.O&S NOT ,[INCLUDE •BL XIC tt+l sll.l: %
4'001, SPA OR MMI°I�.&Y A51PROAC H
C E: MOM C(7149TRUC T101I 2,924.00 OF
PoRcl11p'ATIO, 235.06 Sk
OAWWWAXk'`L" RT 470.00 SP
EVIMATED COW Qr,o 1%7MYJCr'.tt�.S_p3
MA17.1.0
00myrJ3l60`holllIVE 101.000.418-0W 1111.33.00
ipb�.+�t.3)+i�4/�9?�pk'CK IMF, 3y593-}318 $23p4p.7A
ynpO��gl•^fp?�U00-
"�il�l."1 ANICAL, FEE b01 Wick --421.0.°00 5130-30
ELEV711XAL FW', 101-000-420-000 $169,7A
;PWMB"MGYet 101-0004-19-000 $175.?5
S'1`RONO b1011(X9 M 0.1?Z,91D 10 1 -MAO-24 1 -000
ORPaDING, WE 10111000 -MI -1000 S10;OG
L)P,'erZL0PZR. i.4F/!T'ACT VE.2
,ART IN Pt SL'iC P1..Afi.t fa -.A031'E:iYdC3.000-445.000 Si00,29
4
):.x 31 P:R•L-PAM PM,
$0.00
RECEIPTDATE
r; �4
BY
bAT I H�
INSPECTOR
-....FIN...
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/
�/�
Underground Ducts
Forms & Footings
.I)j2 (lam
Ducts
Slab Grade
Return Air
CEJ
Steel
,(� _
/ C
Combustion Air
Roof Deck-�9—
Exhaust Fans
O.K. to Wrap
Framing
_
F.A.U.
Compressor
_
Insulation
3�3 — Z
Vents
Fireplace P.L.
Fireplace T.O.
Grills
Fans &Controls
_j
Party Wall Insulation
(I %
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
_
s
Approval to Cover
I
Equipment Location
I s
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Waste Lines I Z�/3 �,
Electric Final
Heater Final
Water Piping
I Ly(A
Plumbing Final
Plumbing Top Out
_2—
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
//
3_/_ �/
Pool Cover
-
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Utility Notice (Perm)
�,�p—