SFD (0111-203)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
dlws I
Date r Signature of Contractors''
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 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 �°YJ� n ri,uxr� 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' com • ens tion laws of California, nd agree that if,1-6nuld become
subject to the workers' compensation provisions of Sectio6 3700 9f the Labor
Code, I. shall �(orthwith comply with those provisions $
Date:aApplicant.:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil:fines up to $100,000,. in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
'2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days .from date of issuance of such
permit, or cessation of work for 180 days_ will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspectionrpui .1rp6 es`-) Z.
Signature (Owner/Agent) Date.,., i
i
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0.111-4W. TRACT
JOB SITE
APN
ADDRESS '�-j�l ,Y.��,��Mi�':g��T ��� r��'.'Si�'�, . .
�^.�� •� 't
OWNER
CONTRACTOR / DESIGNER / EN (NEER
11) DMERT MINE TORdc iIN L'
SPAP 81 C.<JN:1TRUC;` 109
1y736
79-29yY,�)q-.$v���xi3��,' 440 �a�.fi.;Iv`,t`A,CR.,
�CPC)BTTO��[r:?��a / t. AA,•;��gg fifi��
,LYS. QUIN A CA 922..53
Lk QLI' q-T_Ai. C A 92255* -4 ' .
"750'ili 1.1941, C-Blb- 2996
USE OF PERMIT
MIME FAMi'i..YMMZ.,i..�f IG
a3FDd L,0T 36 PLAX FY3R. ,PI.+RMIT WES7hOT IHC&01)E,fif ":XWAL,l:,4
CUSTOM CONSTRUCTION 2,924,00 SY
QCi1TCH€F''.ATI.0 235.00 SY
0ARAOPdC,AARPORT 470,00 3F
.iLnG.YUMAM (14001gr Ole CONY E�Aw,a.3 i.110.la
240,117.10
CONRTRUCTION IFT2 101-000-418-000 $1,133,00
PLAN CHECK FIFE 1014D"39'-318 t8 $232.24
M.ti,C fMNIC r' L FES 101-000.4:1.000 $130.50
9L=tAW*A1,R &P- 101-000-42."00 OKA
Pk:UMBrNa FYI' 101.000.419-000 $11M-75
•y712:OlLO N?3T1011 YELP . k'+'ffISM 1 0' 1 -001D -2A 1 ^000
0pF cs 67SAd' a 1YFIE 101-000.423"000.
'ART 1H IITUBLIC SLACES - iM911270-900.445-000 $00.29
SUB -TOTAL CCrA3SWUl(Y1109 AND PLAN C EEZ
$:3,11��.i1dz
LESS 1"'R&PAC.7 ah' . O
$0,00
TOTAL L MOUT I',1sES DUE NOW
�/i 2a4im�
RECEIPT
DATE
f
BY i
d
DATE FINALED
INSPECTOR
/nom✓ " R'i: ' :.'
�: (
���—�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
2, -�2 %, Z
Underground Ducts
Forms &Footings
2� Z� , �
Ducts
Slab Grade
�_�
Return Air
Steel
z—
Combustion Air
Roof Deckz
O.K. to Wrap
_ Z
S' - Z.— Z-
Exhaust Fans
F.A.U.
Framing
Compressor
'Insulation
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.`
Fans & Controls
Party Wall Insulation
_ r�Y'U
Condensate Lines
01
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
��/ — OZ S
POOLS - SPAS
BLOCKWALL APPROVALS
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
Waste Lines
— —
Electric Final
Heater Final
Water Piping
_ �—
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
2-- L $'
Pool Cover
Sewer Connection
z 2 y
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%�p
Utility Notice (Perm)