SFD (9903-048)' LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 0 (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. DaW.,
/ate, Signature of Contractorr/* 55S' / -
OWNER -BUILDER DECLARATION'
I`hereby'affirm under penalty of perjury that.) am exempt from the Contractor's
License Law for the following reason:
( ) .+'1„.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):' . ,:. .` r • , . , ... -
( itam'exempt under Section '.' B&P.C. for this reason
DateSignature of ,Owner r'k
: WORKER'S COMPENSATION DECLARATION••
I xheireby affirm under- penalty of., perjury one of the following declarations:
) I-ha4and'will maintain a certificate.of consent to self -insure for workers'
compensation, as'provided for by Section 3700 of the Labor_ Code, 'for .ile
performance of the work for which this permit; is issued.
and will maintain workers' compensation insurance, as required by
S 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.
-ITA . F L1;�7I i fX{649 LT?�!'1'0007.3M
(This section need not be.completed If the permit valuation is for $100.00 or less).
(; ). (;certify that in the.performance of the work for which this' permit is issued;
I* shalt 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 prov1sions�gf�Secti1 n' , 760 of the Labor
Cdde'I..shalI forthwith comply with those provisions.
Date:_(�_r_ `_/� Applicant /
Warning: failure to secure Workers' Compensatio, 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, forthson 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
f,' any per'rr it.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
t work is not- commenced• within 180 days from date of iissuance of such
p,ermit,tor cessation of work for 180 days will subject permit to cancellation.
Icertify 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 for inspection purposes. ` F:
Sigi`natuie, (Owner/Agent) tom' Dete;% `
BUILDING PERMIT PERMIT#
,
DATE VALUATION LOT 9"3-048 TRACT
3/2-.5/99 $220,852-.00 25 28912
JOB SITE
ADDRESS
APN
49�7780 M ISSWN DRIVE MM, ST
649;:Y 1.0-0iD5
OWNER ''
.7�T
CONTRACTOR / DESIGNER / ENGINEER
Tyy t? i?pY l�p� C �79� t
.D..tJi:Si.RTDF%1'L'L�,li'l�1.C:N ''
i2i.Sii:V. S CONMVCl.lON
P.O. BOX 171 a
79-°t9 � R.01040 :1,A. QLzlh"3' fi DR.
A QUMA CA 92253
LA QUINTA C:A. 92253
f: (760)771-1941 0000 2996
USE OF PERMIT `
s
LOT 25, i?d.Ai4i �]-�r�? �.f 12R%i.� >►��� riOT tNG"Z.'clD� tai-Ot. C.�va1;i.� Vit
OOL:Ia1, AN CH CK'r EB RI1011C M, 7. ,% FOR MUL r1P.LF 113,911ANCE OF
AMT, 'I9LIa 1tiT TYPE, r.
� `�•�,�iJ�:il{)
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��l:i'1�(✓3V� 4�(.}�f�'liltiC:�.���i �.�
1
P(AC13 P ATIO 26�.U0' I"
GARA,CiW(."•I#1'�PORT 614.00 S
ID CO.,ES1IMATI�
4
PE1dM;I t FEE SUAIA ARX'
CONS•a'RU(-PION FIM” 1.0.1-000-4111-M �l,i1t'►3.(�
PLAN CM.0 K F IQJ-000-139-3119 �2,ty ata
NfEC-14ANTC:AL M% ' . 1.E1:i-0(10-A21.00fJ �105.U(i
I'i,8C.VR1CA1„ FEE 101-000-42ti-000 lG .p3
Pr Lfl (SING FEE :101-000-4.1.9•-000 $179.25
TRONCi MOTION FFR— RE-SJ,U 1.01-000-241-000 $22.09
CRA"DING FEE 101-000-423-000 $20.00
I1.iFRASTWO TURF k FE 225-000-443-.342 94,f$89,2
A:ItT.(N PUBLIC. PLACES -RESIN `701.000-25:5-000 $302..13
SUB -TOTAL CONSTRUCT10'N .A1ND PLillN� C14E(C7;yK
y C�
MOO
TOTAL 'PERA RT FEES DUE NOW'
S6,960.o,
/4
RECEIPT z
DATEBYE
,y
DATE FINALED
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
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 60 1
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test Gv
Appliances
Final
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)
COMMENTS: