SFD (9903-032)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
Dat' eSignature of Contr ctor ^^
" OWNER -BUILDER DECHfARATION
l heieby'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
s . ' WORKER'S COMPENSATION DECLARATION
I Hereby affirm under penalty of perjury one of the following declarations:
(
).J have and will maintaina.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.
(.''•) -1 have and will maintain workers' compensation insurance, as required by
$ction 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:
Cartier Policy No.
1'Alr t%
(This section n ed not a completed if the permit valuation is for $100. or less).
() I certify, that in the performance of the work for which this permit is issued,
I-sliall 'not employ any person in any manner so as to become subject to the
workers' •compensation laws of California, and agree bat` I should become
subject to the workers'. con ensation revisions ofSection 3700 of the Labor
1� ,. p ',.p t 7 -
C/de; Ishall forthwith comply with those provisions.
'Pate:/. " �r. f: Applicant C -: .7/ --
Warning: Failure to secure Workers' Compennsation�coverage is unlaw ul 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 r 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, indemnity
& 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 repre%sentatives of this City to enter u7'..
the above-mentioned tproperty for inspection purposes.
Signature (Owner/Agent) Dat/a ' • -
BPERMIT PERMIT#
DATE VALUATION - LOT TRACT
3125199 $22%852.00 o 28912
JOB SITE ""
APN
ADDRESS
9-460 MISSION DRIVE WEST
649410-00S
OWNER i
CONTRACTOR/DESIGNER/ENGINEER
T.D. JDE'SkRT DE VELCIPMEN'T'
SPARKS CONS" -RUCTION
1 O. BUX 1710
79-295 RANCHO LA QWNTA DR,
LA QUINTA CA, 02253
J,A. QUI NTA CA M2253
t7g771-13=11 C13.l; 29%
-
:r
USE OF PERMIT,
1.0T 9, PLAN F. -1 -SM -P ER.k.1fT Dt" 0 NOT INGi.UDF BLOCK WAILS OR
AUCJ.I.:PLAN CF�:;C'%..1�S.R�p%rC'rt� 7s�sFc�� t4n1Y r.l}�1,}'s'f5'iil.�`NYF �3.� .
fi.AR. ,. U1 AM XPi'
CUMN.1 CONS`I'12'UB.'°ION 2,635.00 S1•
PORCNI A lO 267,N SF
GNIRAGWARPORT 614.60 SF
SO4'f1<1WA U'�D CaST OF CONSTRUCTION
220,S5.2.110
PC, RMIT FEE ,AthiC4fe'1.T! Y
CONS71R.UCTI.0 N FTM, 101-000_41.8-000 ` 4063.00
MAN (3i:6CK. frEE 101400-439-315 1217.40
;tiiE;Ct1:ANIC.AL EE 101-000421-000 $105100
ELECrRJCA:L FW 101.000-420-040 S1fi^.0.1
11LUMl` INC3.1 FE 1.01-000.419-000 $179.2.5
STRObdGMOTION FEE -'1 ESW lUl-000-2.41-000
GRADING FEW 101-000-423-000 �2t1.At1
.
INF12AS`MUCTU EI S'F'r 225--01.10-43-.342
AitT TN :PUBL.IC .PLACN4 - FZ S' D 701-000-255-000 $302.13
S[l:13IDTAL CONS'I'1 UCTION AND PLAN CHECK
-$6,960.65
USS P-RE-PA.I"c? HUZ S
4�t1.CJi1.
TOTAL P.ERAU T FEES DUE NOW
$6,960.65
RECEIPT
DATE �+
BY/,f%
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
- S XLec,
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
may!
Drywall - Int. Lath
Final
Final — 2
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
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
. Z O af
Pool Cover
Sewer Connection
(i Zp
Encapsulation
Gas Piping
Gas Test
. Z
Appliances
Final
Final / -
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -/
Utility Notice (Perm) o' Gf
COMMENTS: