SFD (9907-067)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
bCh pter 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 1
4074
ate /— 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:
( ) l.; 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.
'W 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 Policy No.
STATE F L NED 046 6073381
(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 bec_orne- ect to the
workers' compensation laws of California; artd agree that if I shoulalloecome
subject to the workers' compensation provlslofs of Section 3700 of th Labor
Coded It II/1Art With comply with those pr Istons.
at �{ Applicant
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
fora 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 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,an State laws relating to the building
construction, and hereby authorize representativ s of this City to enter upon
the above-mentioned property fornction pu
ignature (Owner/Agen7 rsek5
- PERMIT# -
BUILDING PERMIT,�d�,�,
DATE VALUATION�������� LOT .,,fid TRACT
28912?
%lef,
7
ADDRESS 'Y�'- iflt f7 .�1+.7 47)�i �[iil(�r.E%J--'.L JOB SITIt
APN 649-210-006
WNER
CONTRACTOR / DESIGNER / ENGINEER
-1,J) r-.f!k1:0-r' nr,trcr G'rlb t�",rShFi'
e ,1 .: a.�fm xI !J.1... y L, f H' .LF't .i
:1"'AR ,S 1-1nkTfP'Fr,1•i ICI ihAf
t •1. baAl 1W .,.w4 4 a�.ta
PO BOX 1116
791-295 RANO HO LA QUL'+tifl :ii.R.
LA QLTIWrA CA 92253
LA. QU•tW17A CA 92253
x76'(17714941 C81,# 2996
USE OF PERMIT
SINGLE PA�vIiLY W.ELL INg
b� -,LOT 3-4 PLAN R2 - d=M- 11T WES IiO x I C UDE fif OCia. �i 71LL
t,)R:t POOL. .
' 1d 4.:! f�VA� tp�l�+T R l�Vl.. �iL'i� p•7Li:�4 h.11�• .
T'Ciftit 1�t,A fTCii5.00 SF
GARA(WIC:AIl:C'ORX 470.00 SF
if.���{i'i�� Y At .� ��.�s'i�il•.s.�^��� .i,i;� a tici�Y
s vc%a �7. sty
PERMIT FEE SUMMARY
CONS'1 RLfe" 1'1OiN FEE 101-U(D()418-ow S1, 133.00
PLAN CKMI prF, 01-M.0-43,9-318 $92 _.0
i'141'3CHAMCA1>F,L; $O.i,(;()0-94r 5300 $�130.SO
EL EIC'f`tt CAL FE 101-M-420-003 5169,24
PIXIN(K NO.1'FAR .10I. -400 -419 -WO $175.75
S'1'` ONO 1Nu*•1`1•C'N F R -RE 101-000-241-000 $24.01
ORM) 101 -NO -493-000 $2v.Qt1
INFR.ASIRUC"i$1 P F 225-W-443-342 $3,332.31
AtCr 3N 1't71:3IAC FL AC.FS - €tESiC 701-000-255~000 S3SLr.aJ
51713-WFAI,, C ON . R'f ACTION AND PLAN C140,C K
$9,264.0
LESS P.M. -PAID FEES.
$0.00
�,F
•1r3...F w�-I4 v3
•s....
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings�c9
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap
- / - - jZ
F.A.U.
Framing
- -
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final 2
Final
cc/
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
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
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�-tJ
Utility Notice (Perm) ,.