9803-217 (SFD)U)
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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. Class Exp. Date
69064> N 6930198
4Date Signature of Contractor e �
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&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.
(y) 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.
STATS FUND 035-97-11430
(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
sy6ject to the workers' compensation prove Ions of Section 3700 of the Labor
Code, 1 2�allgrpith comply with those ov' iehs.
Date: r 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 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 thatthe above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the/above-mentioned property fo Inspection purposes.
/Signature (Owner/Agent) C Date S
PERMIT # CONTROL #
BUILDING PERMIT
9803,217
VALUATION $li.91♦4 6ALOT 41 TRACT
DATE F A0,
JOB SITE
ADDRESS 78-645 CASTLE PINES DR.
APN 769-740-841
OWNER CONTRACTOR/DESIGNER/ENGINEER
R1T H.0_ MES LLC IMIES Ail.m`'s' wC,
Y.O.330_X810 1425 E. LKIIVERWY DRIVE
LA. QUINTA CA 92253 PHOENIX' AZ 85034
(102)257-1656 CBL# 4990
USE OF PERMIT
, -D o
PLAN 10RA - SFD -1217 HOBS @ 1,A QT i1NTA FA1fi.WkW9
APR n
s•
C:USTOMCQN8TRUC'rION 2,.1.80.00 CITY ®
LA QUIN_r1A
PORC (PATIO 78.00+. 8F -
oAAACfH1CARPmi.' 462.00 nils
;,STINIATED cosi' O.k+ CONSTRUIC'iTKY
:t 19,1 t i.ti11
PERMIT FEE SUMACILRY
C OINS'f'12UCTION F 101_0004184)00 S919.50
PLAN CHECK FEE 101-000-439-318 S756.0
MECHANICAL 1=i'>:: 101-O(Ak-12I-Ot)(f $98.50
hLE(''!fRICA1, FEE I01A00-420-000 $143.04
PL U&IBiNG FEE 1.01-000-11.9-000 5156.50
STRONG MOTION FFM - R1381D 101-000-241-000 317 99
GRAL)1RO FE 101.000.4:23-00(1 $20.00
.INFRAS'.fR0C'rUPJ,3 FEB 225-0(10.443-342 $4,021.74
AWC iN PU:BLIC.PLAC'F..3 - RESID e011-000-255-000 $199.19
SUB-TMAL CONSTRUC310N !111X3 PLAN CtIECK
$6,337.01
LESS PRE -PAID RE171
$0.00
TOTAL PERMIT FUS DUE NOW
$6,337.01
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
�i
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final i I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
I 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
t
Final
UU14 Notice (Perm)
COMMENTS: