SFD (0111-175)LICENSED CONTRACTOR DECLARATION
Q-areby 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
he
614�074 MC
a
DateSignature of Contractor=` -a
,X OWNER -BUILDER DECLARATION,
1 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).
( ) -1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ). •1 am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby'affirm'uhd r 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.
(, ) f have and will maintain workers' compensation insurance, as required by
Section 3700 of tie Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier.d�7t& Sx81:DISC? Policy No.46•t7117;i9
(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 mannerso as to become subject to the
workefs' compensation laws of Calif ornia-and"agree that if (,.should,
become
subject',to the woders compensation'provislons of Section`3700bf the Labor
Code,:I shaltfo hwith comply.with,those provisions. ,r^'
Date., t r �� Applicant 1
y .
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. M1:
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 hereby authorize eepreserltatives of this City to enter upon
the above-mentioned property for. Inspection purposes. 7r �
Si 9nature Owner/A entf. _ 'Date
( 9 )—
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
• 4 $OX2e0 29451'-2
JOB SITE
APN
ADDRESS 794luo MT11510VI D.9 M1.11 EWE
649-1104*2
OWNER
CONTRACTOR / DESIGNER / ENGINEER
`m �t,�^t�...�EL.Y,I'�+Ty �ti�E .�I Gl�.P'Uc� M. ,
kyl:�9.�r�.t.{K.S'�/.lsP.1.4�grMR�UCI1i,•.f�./.gi�Np+�a
O J�:.y�IN i. 17 b A ..
p
'J.9�°M• '5 �;'A`6�V�,+. -10 3..dk IQV11,, to ��R
.� __ ,
,c !'3 `f.I.L y" 1. CA 9. 253T�Qllxrt,
CA 92253
('?6K9j�`1 Y •] 94.1 C°HIA 2996
USE OF PERMIT
dk n IDT a PLAN Lei, x�;'�R]' IT DC1.6's..K NOT W:1XIDE BUD= `WAU 7,
POOL, S�",k DWIVEW&V APPROACH
CUSTOM CONSTRUCTION SFr
T'Ci11MPAT i6 3tS'i.f10 S
W,nWIRD COST OF coy,,�-.nzuconon
2,20,952.00
,PKR .1'r ME SUMMARY I
CONSTRUCTION FEE1sl,,0�no
10r�1-00n-41y69=0y00y
CikM CiSKX tE14
MXMIMIC.fi4K9. 101-90 -4Z1-000 S10100
?L8CTPZ1C'k'tf,.RIE 1,61-t' OW2("00 a�X6d.�i
1
PLC3MBIWO FIR 141-000,419.000 t17.912$
"Thi,F�b'fiiOMOTION FE,;:'.RE.SID 101-0001.241-•000 1(2�!
6RADINOFIR181 101-0)0-493-000 826,09
1'3PIVITLOP51,907.00
,&!JT',g4 PUMz IC P], AC'E'S'- 1w'tt"..0iiK 2:710000-445-000 $42.13
NLwdfL
' SUB -TOTAL 0,. yXKrKV/+MMy'ALV RUN'
$3,726,3$ $
S,.&IM PRF PIVD FEES
V),00
TOTAL YXMM)MES PUE NOW
RECEIPT
DATE
BY
DATE.F4NfED INSPECTOR
ro
,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
%/ /
t�–
Underground Ducts
Forms & Footings
��
Ducts
_
Slab Grade
Return Air
Steel
Combustion Air .
Roof Deck
2 - ig _a _2
Exhaust Fans
O.K. to Wrap
07- /-'T– 2S
F.A.U.
Framing
—C3 Z _
Compressor
Insulation
_�� _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
2:; Z'7�2
Final
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg, Test
Final
I
Gas Piping
PLUMBING APPRO ALS
Gas Test
Electric Final
Waste Lines
_
l_Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
��, j _ S
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
—Z l�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
{
Final
COMMENTS:
Final
– 7_-t,�2
Utility Notice (Gas)
67�T.2 -
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)
15_z3 `Z