SFD (0004-156)'LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of Division 3 of the Business ar
Professionals Code, and my License is in full force and effect.
License # , Lic. Class Exp. Date
'
478689 B r.. . (3 /29/21
Date `" ! 7-�'�P'Signature•of Contractor`s
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sol
compensation, will do the work, and the structure is not intended or offered f(
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with license
contractors to construct the project (Sec. 7044, Business & Professional
Code).
O 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 declaration:
( ) I.have.and will maintain a certificate of consent to self -insure for worker
compensation, as provided for by Section 3700 of the Labor Code, for th
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required It
Section. 3700 of the Labor Code, for the performance of the 'work for which thi
permit is issued. My workers' compensation insurance carrier & policy no. ar(
Carrier GOL DE'N EACLE Policy No. HWC .°,47"1400
(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 issue(
I shall not employ any person in any manner so as to become subject to th
workers' compensation laws of California, and agree that if I should becom
subject to the workers' compensation provisions of Section 3700 of the Lab(
Code, I.tshall fortU#ith comply with those, provisions.
Date: f `Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful an
shall subject an employer to criminal penalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 370
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safet
for a permit subject to the conditions and restrictions set forth on hi
application.
1. Each person upon whose behalf this application is made & each person i
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to, & shall, indemnif
& hold harmless the City of La Quinta, its officers, agents and employee;
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180. days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatior
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property fo inspection purposes. �-
Signature (Owner/Agent)nh Date'
BUILDING PERMIT PE IT"_
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DATE VAI ATION LOT % / POW- 5 �% TRACT
04h 71200 V.42"2557.60 � � 1,29651 s
JOB SITE 'r'
APN
ADDRESS
7451-330-030
OWNER
CONTRACTOR / DESIGNER / ENGINEER y
SOUTIrw flwi s•T: LC
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1430F,CEWMA,11TAVETf.r 10
0131?.1+iC CA 92886
.f.rti(,1TI,NTA CA 02,253 e4' --�
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1;114)633.7260 CIL � F ,1
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USE OF PERMIT
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0.4 V. Q
WCasila PERMIT ITC}.RS"NOT INCLUDE B.t.CJCK
WALL OR POOL, '
CUSTOM CQNSTRUC:TION WIN 81z
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POPICHIPA'r10 1,039.00 SF
GA.RAOEICAUI ORT W.00 SF
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xgnmA,= comer ov Cowstx1;`ucrion
332A57"
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CONSTRU60N FEE 1014M.418-01130 ' $1,59.3150
I'
PLAN CHECK FEE 101•-000-439.319 $1,292.61
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MECFIANICA1.,FEE 101-000.421.000 Y110160
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it
ELEC'MCAL FEE 104, ••0120.420-1200 $229.46
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PLUM111140 IM% 101.000-419.000 $760.25
MONO MOTION FE - RESID 101-000-241-000 $37.:17
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GRADING FRE 101-000-422i-000 $20.00
DEVEWPER )IMPACT 1°1~1; $1,907.00
6
ART 119 PUBLIC 1'%AW : RE.t` M 701.000-255.000 5434.35
FZE DEPOSIT 101-000.439.318 •$1,0110.00
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KID-1°0fAL C0T~Ttii XLTC:M0N AND PLAN C - MGIC
$5,888.54
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IMS PRF,' PAID) lM
41,000.00
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TOTAL P 41�_3M—Yi 1r��S DUE NOW
$4,088,1.i+
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3
RECEIPT
DATE
BY
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
1/0/01
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Footings
_ A
Electric Bond
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
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: