SFD (9808-103)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. ClassExp. Date
tt ��74-4,367 B i213119�1
Date 41gnature of Contractor ,
OWNER -BUILDER DEOLARATION
I hereby affirm under penalty of perjury t f 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 isnot 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
pe ormance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Sec 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 Policy No. ,
S T ATT FUYD 150,1093-98
(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 rdSrisions o�,Sect6 he Labor
ode, I shall forthwi . comply with tho ision .
Date;`= Applicant
Warning: Failure to secure Wor a s' Compensation c erage is unlawful and
shall subject an employer to/6i lrlr (nal penalties and ci II fines up to $100,000, in
addition to the cost of c/om nsation, 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 .oal'his . .
application.
1. Each person upon whose behalf this application is made & eachperson at
whose request and for.whose benefit work is performed under or pursuant.6
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, and Stateilawsrelating to the building
construction, and hereby authorize representatives -of this City to enter upon
the -'above-mentioned property for Insp. ction purpo :es!
Signature (Owner/Agent) / Date As
BUILDING PERMIT PERMIT# CONTROL#
9Osiltl-�S);3
p� p�
DATE^ /prf VALUATION �S'ITLZrf! 15'. �eit� LOT C�', 2 TRACT i�i.:'/..JA{jl9
w
JOB SITE 77-99S CAMP, MOMS �'r'�.i.' Y
APN 7774-49"26
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
yr(JRLDI?EVELOPMEN'T',R-11C
li+Oi'..:171eT�`�r��Q;�
1'0 BOXX 13287
PO 1340"11%,132817
RA1 M DESFIRT CA 9225.5
PAL NI DESEV' CA 9224
i?C>t)?'771-SS 11 Ct3L:r 50218
USE OF PERMIT
3FD - KAW c D-00 NOT 1KCLU.DR .U' 0C K WAU; OR .i✓t;Cis..
TRA(7s' CaN;�'t'}2iJ 4'1074 ?.J041.00':.1
PORCA'fzA:'T10 36,00 ST'
GARAGOC;A"C)RT 605.0 Sty
t;:0t[S°D' U(,';" 11ON b'M 1.01-000418-000 ST44.00
.
PLAN (7KCK:FE? 61 101-000-4P-318 1621.715
IN EC•`Q ANICAL FEE 1101.000-421-0100 "0..00
RECITdc;IV, 1196 101-000420-000 U88.23
PLtJR'1:t3ON'G FEE 101-000.•419.000 0.39.50
STRONG FIN_ R S1i) 101-0()0 24).«00n
tiiF A NCr FAEs 101-000423-000 $2ti.tiU
11�'R, Z 1"kV&,1'QR1ZrEE 22-5-000-443-34.2
PR EC1SE PLAN 101-000-441-345 sLS.op
►SAT IN PUB1,1C PLACES - RE�S_vr; .701-000-255.091 0
ER DEPOSIT \401• 30-439.31£8
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.v j,•7y. �t etd AT,
$4,704.98
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs f
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
_
SteelCombustion
Air
Roof Deck //
Exhaust Fans
O.K. to Wrap Z/
F.A.U.
Framing _Tjj_�,� i
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath L
Drywall - Int. Lath /
Final
Final
POOLS - SPAS
BLOCKWALL AP OVALS
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
_
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:
FinalUtility
Notice 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
r
Final
Utility Notice (Perm) 2.3 -