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/ LICENSED CONTRACTOR DECLARATION
I� irm under penalty of perjury that I am licensed under provisions of
_ er 9 (commencing with Section 7000) of Division 3 of the Business and
Prof. ode, and my License is in full force and effect.
Lic is Lic. Class Exp. Date
ip` 7 41 8 $ 10/91!2(
Signature of Contractor • ; 1
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.
( ) 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 GOLDEN KAOILE IN& Policy No. NWC-544068.-02
(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 provisions of Section 3700 of the Labor
,Rode, I shall forthwith comply with those,provisions.
/ Date: t- / /r'a'n Applicant—
L11
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 that the above information is
correct. I agree to comply with all City, and State laws relating to the building
const ction, and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspection purposes.
Signature (Owner/Agent)2' 4�' r` /l-� Date •��
BUILDING PERMIT • PERMIT#
DATE VALUATION LOT 0005e-0 TRACT
$2311W.00 26 28719
JOB SITE
ADDRESS 79-7 5r�.TI �U
APN
769-4SO.042
OWNER
CONTRACTOR / DESIGNER / EN (NEER
carrmy cROWWL COMAURrm
cF>n VRY'C' ROWKL COfAMLWf=
1535 SO, °D' STRMT, VM, 0200
1535 30. °D° EMRL, = 317.0200
SAN 1;)1R ARDWO CA. 92408
SAIF RF"Ak1=21A10 OA 92A08
(909)391>6007 C8LO 2170
USE OF PERMIT
SWOLE FA]s)MY DWELT -WO
VD -PERMIT DOES NOT INCLUDE SWCK WALLS OR POOL 75°% PLAN
CfiWK FEE REDUCTION POR .MULTIPU ISSUANCE Of; SAME PLAN TYKE,
CUSTOM CONSTRUCT)ON 4815.00 SF
PORC131PATIO 157.00 Sty
UARAGEiC.ARPOPtT (513) 9,9 f6.40
14S`T VA= COST OF C011gMRIIC"`n01N'
231.,"5.t1t?
PE •r 17ME SUMMARY
CONSTRUCTION FEE 101.000.418.000 51,101..0
r•..t
1-j
PLAN CHECK FEE 101-000-4.39-318 $221.47
MECHANICAL FEE 101-000-4.21-000 $93.50
ELWfR.ICALPER 101-000-420-000 $142.21
PLUMBING FEE 101.0004414.000 $1.65,50
tfj
STR.ONO MOTION FEE • R&SID 101-000-24 1-000 $23.14
1 ( °
GRADING _-M- E 101.000-423.000 $20,00
` 1''
DEVELOPER IMPACT P%E $1,907.00
ART IN PUBLIC PLACES - USM 701.000-25.5.000
9(TS-TOTAL CONSTRITCnOX AND PLAN CI-MCK.,
$3,761.? 0
7.. S3 PRR-PALD F
$0.00
TOTAL PIRMT1+US DUE NOW
&+,76L?0
RECEIPT
DATE
BYE "',N)
L.C. _. �f
ATE
DFINALED
INSPECTOR 771
-90 w
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
4F0r,(,,;&
APPROVALS
MECHANICAL APPROVALS
ks
Underground Ducts
Footings
Ducts
Slab Grade
o o
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
�,�p�ap
F.A.U.
Framing
/ ' oa
Compressor
Insulation
/ Q ,�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
Steel
POO S -/SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Localion
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
7ZO-00
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer LateralPool
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. ,00
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: