9905-191 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I �m 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
743025 6 IWO/191.
Signature of C
\,Pate ontractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( )' 1, as owner of the. property, am exclusively contracting 6th 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.
(� ) I have and will maintain workers' compensation insurance, as required by
S Wfibn 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 l.ATh F L) N I) 144OL25-98
(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 rovisions,4of Section 3700 of the Labor
Code, I shall forthwith comply with tl�plc provigions/
Dat4: Applicant— A VIL
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subje ' ct an employer to criminal penaltie"s and civil fines up to $100,000, in
additioh 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
�vhose 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 that the above information is
cbrrect. I agree to comply with all City, and State laws relating to the building
construction, and hereby authoriz,61 representatives of this City to enter upon
the above-mentioned property for/ins;�ectioh �urposes.
/ I / / -
'Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
9,90.5-191
DATE VALUATION S38413117.64.111 LOT 16 TRACT LLA 97-2,S5
t< I - e'l C1
JOB -SITE'
APN
ADDRESS 79-3S6 CETRINO
769-"0-029
OWNER
CONTRACTOR / DESIGNER ENGINEER
NIARVIN F10,%1ES
NIARVfN 1101AJFS
78-080 CALLE EKrADO KIV 201
78-0,80 CjWX Egi*.ADO STE 201
1AQ IAWA CA, 92253
LA QUIKCA CA, 92253
060)771-2567 C1111 5401
USE OF PERMIT
SiNGLE PAMILY EAVELLING
SWD - PLtW 2AR, LOT 16, - PFRMIT DOF.S NOT.W.LVINUILOCK
WALLS OR PCK)II. IFEAt JJ1A hrtrl _2M,
(XV0iM CONSIRUCTION 4.580.00 SF
PORCkMPATtO SWAKI SP,
(JARA.00CARPOWY A 11.00 SIF
ENT1 MATED COST 0 F CONST11 VCf I ON
333,317.60
PERMIT FEE SV[%1hC%,,RY
CONS(UtKUMUN FIT 101-(K)0-418-00 0
Pf, AN rf 4EDs' FM,* 10!I 4Y)0-419-348
M- 1014)00-421-000 $130,M
RECTRICAL FEE 101-000-420-000 S2, 7 �5, 5 2
STR0 Nil MOVON FFF - RPSO) t 0 1 -000-241 -000
GRAI ANG FM-' 101- M3423 -OW
INFRASIRUCIVRE M 225-000-44-1-342 U,00(wo
ART IN 111f.T8111C PLACES - RFS11" 701-00-255-001) S708.29
Rl J13,M)TAL AND PLAN CRT-i'CK
01
LESS PRr-PIVID ITIS
$0.00
VP'At, PIERMtT FEES DUE NOW
REC
ML VII.,.r
DATE
I �� . -7,
DATE FINALE
PECTOR
INSPECTION RECORD*
OPE RATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
SetBacks
� e—r
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
Framing
0/ 'p-
_T411(
Ag_/z
F.A.U.
compressor
Insulation
I?
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Llr*s
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
C/? at
41111
, .
Final
F
Final .::cg I
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
oy
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
2 —
Appliances
Final
Final
Utility'Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Win*n'g
Low Voltage Wiring
Fixtures
Main'SerVice
SubPan.els
Exterior Receptacles
G.F.I.
-- - -------
Smoke Detectors
Temp. Use of Power
Final. (2w
Utift Notice (Per m)- C,* 0 &
COMMENTS:
7 1
f