SFD (0104-262)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT
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 DATE VALUATION LOT
Professionals Code, and my License is in full force and effect.a"'�$��7.9(�
License # Lic. Class Exp. Date
JOB SITE
....,.,,,,.✓'DRESS
�,d / .^ �." OWNER
geF Signature of Contract tri -- '
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
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&RC. 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.
O� I have and will maintain workers' compensation insurance, as required by
Seciion 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.
(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 agrere'"that if I should become
subject to the workers' compenss do rf✓s provlsl of Section 37,0.0• of the Labor
Code, I shall forthwith comply vyfth those o Islonst
Date: • --ol Applicankr
/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 Applicati6ni is hereby made to the Director of Buildih0ai, i 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 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 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 Sate laws relating to the,building
construction, and hereby. authorize representatives of this City to enter: upon
the above-mentioned properly forriin's�..ect`ion purposes- rt,
Signature (Own er1Agen _-r n ^ Date
.kSI-MR:00K Ms:'13'1�'�.A.TNEW
5140AVH1 MCMADI
COUHAD CA. 92008
PERMIT #
rMM:2 . TRACT ' 1
19147-7
APN
761-140-015
CONTRACTOR /DESIGNER / EN INFER
I MR00 . DLW.' %Pr,('vGi.' CCkt'4ePANY
5140 A�'.f YWA t12t-TC,',?i4'
ARiMAD CA 92 708
(160).504-6868 C: L4 3376
USE OF PERMIT
r�3�3'tRr:1x:�2i�.I„".2' 3�1fiTi'�� �:�€3 •'
SFD-a$00,L 7, PLAN 2L31-- MMABRDOES NOT INCLUDE B LIOCK
WGaANyC WISPA ORRpPLOIVCH DA &rATd
CLJXx o Z615.00 9F
PORCHPAMO 525.00 SF
V�F.�C'bbJ�wt]AU'W1.�•e.l �L�� 1, 51y'Y�Sf,YW
=111 MIFKD Myr We COHNIMUMION
221,157.40
AsER-Mrr ME SUMMARY
CfpMM�,t1f:T'1rDN FIEF 101:000.418-000
af.066-n
PLAN Cgdi GI. 101-000-439-.318
P�41C' t 1)ltu•1�(.FRE 101-009-4 21-000
&1)9.n
VA'X, ;TRJ AJ, ME 101-000-420-000
$135.71
'PLUMBING T'gg . 101-OCK)-489.000
S181.75
VrRONOit 07.10N, E • R13,51D 101 �-000 241-000
baa t o
tf9? 1).CFJd1 .�;Cf 101,0 00-423-000
$20.00
AR -'S IN PUBLIC 1•LAORS - RHSZ1 7031.000.2554XV
,F, mposa 101 -UC 0.43'9-31 a
45W.90
RUB-TOi"ML K, A `.. 1 ° I,KtA7 AND PT.OW CM�'.t C
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CITY OF LA QUINTA
FINANCE DEPT
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RECEIPT DATE / J BY'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings/
Ducts
Slab Grade
_
l
Return Air
Steel
Roof Deck
_
Combustion Air
Exhaust Fans
O.K.�A o
pj
F.A.U.
_y
-raming TJ sij/i
_
Compressor
Insulation
g
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywa11- Int. Lath
/
Final
FinalPOOLS
- SPAS
BLOCKWALL APPROVALS
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
_
-S'�7/��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
7��i l�li
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
��
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
� Y
Utility Notice (Perm)