9908-128 (SFD)LICENSED CONTRACTOR DE&LARAT'10h
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-._�11
License,# Lic. Class Exp. Date
7 025 B
41 - -
0�ate iQ C' Signature of Contractor
1W —I
't
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, aslowner of the"property, am exclusively contracting with licensed
contractors,to. construct the project (Sec. 7044, Business & Profession.al.s
Code).
-1 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��ncl will maintain a certificate of consent to self-iinsure for workers'
compensation,' as -provided for by Section 3700.of the Labor Code, for the
performance of th6work fo� which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Section 370 0 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insur ' ance cafrrier'& policy no. are:
Carrier Policy No:
STA1111111MID
(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 permitAs issued,
I shall not,dmploy any person in any manner�so—dsto become A/1
ubject/to the
workers ",'compensation laws of Californi��and agree that / 1,�KoulAecome
si�pject to the workers' compensdti;n proyisions of SectiA 37-00 of the Labor
Gode, I s all ort with comol�'with-those�provi'-si'ons.
1"bate: 11010 08 'A /CaInt--
Warning: Failure to secure Workers' Compensation coverage is u . nl6f6l and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
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 & ea&i 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 eesult of this application be comes 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 fo cancellation. -
I certify that I have read this application and -,state that the above information is
correct. T�gree to comply with all, CityT�ancl -State law^r lAing to the building
construction, and hereby authorize representatives,,6f this City to enter upon
yth /a bove- mentioned property for inspe-6tion purpo4es:"/
Signature (Owner/Agerit t ---%,Date
PERMIT#
BUILDING PERMIT
DATE YALUATION, �g3-22.gq LOT TRACT
JOB SIfE
ADDRESS 79-4,66 CETROO
APN
'772-110-00,
'6-WNER
CONTRACTOR DESIGNER ENGINEER
CITRUS,
1.11,11DOMN, 410NIES
7"80 CALLE ESTADO TfF, 201
LA QUITrfA CA, V12-53
IA WWI%. CA 0275 i
USE OF PERMIT
PAMM DW-BLUNO
SFU-LOT211,10LAN NOT ]NOLUMIXOCK WMJ,
OR POOL.
I
1,895.00 SF
83,
0101161TRUark)-N, FEE .101 -OW -41k -WO 51.420.0IJ
PLAN (7HR"K, FFF, s 5, 8. n.
NAN',1CAL F M� 0 L) a, - "tiv M", $130.50
7-1
DMIC11,11 11CIAL - r0i SU7,89
numeo"(3. FHE S214.50
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PTRO-40 M711 (Yt4 FhE - RE N.- Y D 10!4100 -241 -fa
;;;,
( FT -1
CRAWN13 M2 $20-00
rn
AWr W PUBLICPLACGS - RF -SID '10 1 -M-255-000 S557,22.
'11VAIACT
DEVELOKR, Fhti S LMWAO
M
LAJ
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ANDPLANCMXX
$5fiM.97
SS P IEP
$10M
TUYA1, VCH'tWiT FUS DUE NOW
S5,067.92
RECEIPT
DATE
BY� . -7
ATE FINALED
C
]INSPECTOR
I, -
INSPECTION RECORD
OPERATION
I DATE
INSPECTOR
OPERATION
I DATE I
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
ca
Underground Ducts
Forms & Footings
Ducts
Slab Grade
1-2_4- -rj
Return Air
Steel Xq ck g
4.4 C-0
Combustion Air
Roof Deck
ExhaustFans
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 917
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
;947-2,-0
Heater Final
-/=77
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Raster
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) �27
COMMENTS: