9808-152 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
ci W Professionals Code, and my License is in full force and effect.
=) Cq License # Lic. Class Exp. Da�
~ Z ti
VD/ate �' [' Signature of Contractor
0 0 ti
I'- U CD OWNER -BUILDER DECLARATION
W Wd I hereby affirm under penalty of perjury that I am exempt -from the Contractor's
co License Law for the following reason:
Z_ ( ) 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).
C'`) () I am exempt under Section , B&P.C. for this reason
In
N Date Signature of Owner
ON
a Q WORKER'S COMPENSATION DECLARATION
p � I hereby affirm under penalty of perjury one of the following declarations:
Lo H 0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X LU 9= compensation, as provided for by Section 3700 of the Labor Code; for the
m0 � Q performance of the work for which this permit is issued.
Q' 0 ( 1) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
Il: Z permit is issued. My workers' compensation insurance carrier & policy no. are:
It Carrier Policy No.
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r C) `I`I'A:`1 Z FUND, 13^,11)9}
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(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 becom u 1 to the
workers' compensation laws of CaliforniaNnd agree that j should become
subject to e w ers' compensation pros ef-S f ' n 3700 of , e Labor
Code, fh�.fpI ith comply with those provisions.
wbate: lll(((��/��/L 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
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 permitissued as a result of this applicaton agrees to, & shall, indemnity
& 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 160 days will subject permit t6;cancellation.
I certify that I have read this application and state that the above information i*_""�
• correct. I agree to Comply with allf-11 , and State laws relating to the building
construction, and'/6reby authofi2e re resentatives of this City to eater upon, ,
the'above-mentioned pr'perty;ra
fo sp tion purp
46
/Signature (Owner Agent) ~� Dat/
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT TRACT
9
5 S.17.1 'Z49.1 t1 f ti 2 ..� , .
JOB SITE
APN
ADDRESS 484V3 4L4SH'A DRIVE
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r >t nr:�a;rf'r:7f?:'I'.1.C�Pljl ri�'T
!
SPARKS (!0NS'rR\ UC'f1("/'
P.0, ly-,IX 17it•
',9-295 RANG• 0 LA QUIN A DR.
1,A QUI -NTA I- A 92253
LA Q11-n"A CA 92253
17139►71-1y.11.
USE OF PERMIT
SFA.- PLAN 6. LOT 41111• HiRNIIT-DOES NOT IN LGEiE RLO%Iti WiU!_L
OR F"001— PLAIN CHECK FEI: Rk-J 1}+:11) 75",•o FOR MULTI -P E ISSUANCE O
SA1'a1F PLAN 7"YOF.
CU-`.iT'Ls'i 0,-,,NTrRUC-`rKiN 7.,(453.00 V.
NOKC-HIPA'1`IO W13.00 .1i
l"AA Rikf10CAlltI)ORT 43ti.Ofl 1141'
Itlol'FINMATFt, 1) C4YST OF C 0 N 8 T 1.110"i 1 ON
C'ONSTR.XIC-110N FET-. 101-1IMAY419-000
1'1.,A#1d CHECK FF_F l ijt -W-439-1 18 S IF%3, 7q
IV1iit_'1T/37NdC�11 FIT, ,!.'J1-000.121-000 SSrh,�'4
i:E ECTR1(: AL 1= FE? 101-000-420-000
PLL�I IBING FEE 101-M-414-000 I6.1: 5
STRONG 114(? 1'Trl}d . 5^1 >JJ3 j 04-QOIt-Za-.l M)tl S I ;1.17
GRADING FEE 10.1 ftC10-4b3-41)0 $20,1:0
IIvTi:A`� i'ttI1G 1 EJRL FEE S3.796.85
ART IN l'U.F. LIC PLA. -CES - RESiL: 7014K)O-255-M) $171!1. 12
a,
P�
_111-TOTn), CC}NMiUC"i"10N AND PLA1N.1,:'F)1aCN
7 f1"I'Eti, 1'F.;ltiil["1 1A'1M;:9!'S DITtl' NrLYtY
tl iF1
RECEIPT
155 V eA
1BY `
DATE FINALED
INSPECTOR
IrJSPECTIOr RECCGR�
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICALS APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Gradeog
G
Return Air
Steel
Combustion Air
Roof Deck
Lo
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 Lathl
Drywall - Int. Lath
Final
Final qPOOLS
SLOCKWALL APPROVALS
- SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Band Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
ZOL
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
1 .
Appliances
Final
Final
Utility Notice (Gas) Q
ELEC7RICAL 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
Utility Notice (Perm) L _!
COMMENTS: