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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
743D25 a 1 VW191
Q/te 0' ignature of Cont
OWNER -BUILDER DECLARATXN
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 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.
J _)_� I have and will maintain workers' compensation insurance, as required by
§&cfion 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.
STATE FUND 1.140111.5-99
(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 mpnner so as to become subject to the
workers' compensation laws of Califo'i �, and agree that if I should become
0
subject to the workers' compensation�srovisions,bf Section 3700 of the Labor
I
Code hall forthwith comply with�wojt provi�,'ns.
Q 1, - r "
opnu� 2� Applicant -x/1 -
Warning: Failure to secure Workers' Con)eensation 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 that the above information is
correct. I agree to comply with all Cii. , and State laws relating to the building
construction, and hereby authoriz/e" epresentatives of this City to enter upon
the above-mentioned property fo ctio Wurposes.
pgnature (Owner/Agent) Date
PERMIT#
BUILDING PERMIT
"PW134
DATE, VALUATION "%,4J7_". LOT 20 TRACT
9
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
CURUS DEVELOPMENT Ur
MARVIN HOMES
51 -370 AV BERMUDAS. M 1
79.,= CALLE WADO M 201
iA WINFA CA 922-53
LA QUWA CA 92253
CB1.# W.7
USE OF PERMIT
SINGLE FAMILY DWELUW
SFI)- i.01 2U. KAbi 2KA - PERMff UxX-,S 1,KjT NaUDE BLOCK WALL
t-* K"L. 7P/* RkAAJCI'ION ON nAN 0iKK PU OR MUITIPLE
I&4VKANC7F i -W SAMF PLAN TYPE
CUSTOM CONNSTRIC710N 4.697.00 SF
f1caCUPATIO 892 (9) SF
43ARAt MUCARPoRT 836vu SF
CITINATrD CTAT Or CWMTRUMON
3114401",
PCUMUt FEE SUMMARY
CONSTRLK,711 )N Flik 101-0(K)-41*40) 3 1,67-20)
Pf. AX 114F('K FFF in 1411410-4 W_.A 19
101-000-4121-000 S1,10 io
"Et-'TR1i.'AL H -F, 101 -000-420-OW
W.UNIBINU F111j., t 0 1 4X)O. 4114 -Aft S2127. 7.5
4TR0W1 h*-�TTCW FVF RP1411T) 101 AW0414M T" 4%
G 101,0W423 0017)
3RAI)VIA1 FLY 1120.00
AK i IN KJHL K' PLAAJ%S - RJsSdl- 70 1 WO $736.34
IMPIkk"r VEP. S 1, 907.11XI
SUW1Y)rr.,kL CY)NS'MTK'T10N AND PLAN C14TZCK
%5,37R 4s
LESS P",-PAILID FEES
$0,00
FOTAI, PERMIT YCKS DUK N()W
RECEIPT
DATE
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�_
1�2_el
Underground Ducts
Forms & Footings
4
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
6 - 411 Ci
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
0 - 0--v - 1,00f
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
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
4�2�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)