SFD (0301-016)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
6,7407= k3I Cr �" • i * C . 7r`<3 flO:y
'Date- X12 X, 1' Signature of Contractor
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
7044, Business & Professionals Code).
(.
I, as owner of thero e ,: p p rty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
() 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.
SecI have and will maintain workers' compensation insurance, as required by
ion 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 S'T¢aT1.iFIND Policy No. 040-7338•7003
(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 -provisions of Section 3700 of.the Labor
Code, i shall forthwith comply with those provision's. j
,Date: / -•F '} Applicant °' ^r 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 aN
whose request and for whose benefit work is performed under orpursuant to
any permit issued as a result of this applicaton agrees to, & shall, inde
& hold harmless the City of La Quinta, its officers, agents and emplo
2. Any permit issued as a result of this application becomes null and vct�Ji
work is not commenced within 180 days from date of issuance of �ICfi�
permit, or cessation of work for 180 days will subject permit to cancejlaLing
I certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the buiconstruction, and hereby authorize representatives of this City to:enter
the above-mentioned property for inspection purposes. '
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
t I'�.� m 36 2S'45I.3
2 w 0 a
JOB SITE
ADDRESS'�dJ,1i5!rti.�L.,+A..CY�.tv,k„,.a.�' a?;
APN, Qel�1.✓tF.d;�
OWNER
CONTRACTOR / DESIGNER / EN INEER
Im DFZ"r.:R`1 'DF1V 01YM1wWr
SPA RKS CONST
PODOX-1716
79-3:95, 10=110. �MITASA,
1A QTTIN7A. CA 92253
1.&qm3`: "l& CA. 922S'i
USE OF PERMIT
'iM, ^- #,..OT 36, PSN G.I. •PD"Lk%MUT 17C➢ftM NOT lAtMUDE 3=11 VYAW,3,
Fuy�0y0, 14,{81FI.h AP�PRO�p,�yc';y ,, 7.51 KOYE
w CpH)
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CUSTOM WNSTRAX'IT1014 463100 0.1111
#?O@'CIMP, e 6'103
CONTfRUCTJON F?X 10 1 -000-41.3 8-000 *11K00
'PIAN C,HEClic FEE 101-000,439-.3ii' $7,1190
W6.'RAi:' IVAL. V, 11:31-000-421-000
T PJ CA L F U, 101-000-420-000
PLIUMB3140 s?i ; 10 .00MI3aC0t3
1"RONU MOTION ME RESK) 10)-M-2411 -000
C*1'd.a4:N—M SFR{
DEVELOPER 1f!'l7WA.D'1' FE
SRT 1313 PUBLIC P141,0M -AMM VO4*0445.03 l
8XM=�,'�'7'rA'{,MIMMUM1014 MOS II X11.3 IC -1 TR
SiS PRE411 K. Ho
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A•
RECEIPT
DATE
BY
DATE FINALED
INSPECT R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
r _
Ducts
Slab Grade
_ �—_3
Return Air
SteelCombustion
Air
Roof Deck
—3
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
= `—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
_
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
r
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
.
Appliances
Final
Final
Utility Notice (Gas)--�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 3
Low Voltage Wiring
Fbdures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: