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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/
/ 711' 2 5 1130119!
a,.
Signature of Contracto'�
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 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
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.
STA11Z 14.11011.15 rr)
(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 f9r which this permit is issued,
I shall not employ any person in any marineC9Sas to becomeisubject to the
workers',, 6ompensation laws of Californi� I aria agree that if lj§hould become
I . .
subjec6o the workers' compensation provisions of Sedtibn 3tOO of the Labor
/0 e, I S 11 fbrthwith comply With,those provisions
at'e �' 1 1�4 Applicant -f_
Warning! 4---
. 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 permitto cancellation.
I certify that I have read this application and state that the ab6ve information is
correct. I agree to comply with all Oitq,'and State I s rela ting to the building
construction, and hereby authorize repre�entativps of this City to enter upon
the at�cve-mentioned property for inspection pu��toses-,
,Signature (Owner/Agent)
PERMIT#
BUILDING PERMIT
DATE J VALUATION LOT TRACT
.3
JOB SIfE I
ADDRESS 79498 0-11,10NO
APN
772-110-047
OWNER
CONTRACTOR / DESIGNER ENGINEER
Cf [RUS DEVELDP!'OUINT LLC
1O.M.ES
N-370 AV BERMWMS, !;rE. I
7S-080 CALLE ESTALO MT-
1101
LA QUINI-A CA 92253
LA QUINMA
CA
922-5.3
CB1,H
5407
USE OF PERMIT
SINC3LE FAMILY DWELLING
IWO- LOT 23, PLAN IXA. - PERNUT 00ES NOT INCLUOI& M,OCK WALL
t-* K -9 -IL 7:i'!** RLUUC-1'10N ON PLAN'4AII.-CW FFX Qk h1VL1PLX,
ISSURANCP CWSANIE PLAN't'"i 6.
C U: 11 T C 1) 1 t C 1 0 It 43 T; Z U C_ n 011 71,815,00 13F
K)RCIOATlu 354AW fAF
()jWA01A:AW_P11Y
ESTIMIX17D COSTOF
PERMIT FER SUMMARY
L)EVELoPER 1MPA(!r 10427.
(IONST"Tif"rlow Frp I fl I -(XXI-A 1 84M V. 4 V AA
MIV4 I'll 1r.CK FIX 10 1 -000-43Q 3' 1 8 $2 0.61
tttfik'11A�WAL rL6 toll -00"21-M $Ou.50
EL1.8,11?JCAL FRE lot-OW42o-000 32.17 89
144 IN01thh-1 F 10 1 410�4104M V 14 "A
1,111tONO NtOTION =6 r1rSID 101 000 V-1 V
kAW_)jNu f -RE
ARTIN PUBLI[i PLAC74S - KESW /01 -000_25.'�-WO 22
C_
1, V V -S PR P, - P.M D F 1; ES
SQ.00
'foTAL PERM I'VEAU4 01JE NOW
S4.7".0
RECEIPT _r
BY,
I
DATE FINALED
I
INSPECTOR
I
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air -
Steel j�7-/t,_n )-�e
W—,
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
4-V
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'e7-. ',—f
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
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
Z_
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
Appliances
Final
Final
Utility Noboe (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)
COMMENTS:
a