9807-270 (SFD). �I LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
LLIa:-
r--
r-
Z
13 , / .10/31/0
ti ate :Signature of Contractor��' '
�D O
J U CD OWNER -BUILDER DECLARATION
LLI W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 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).
( r) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C`•) (} I am exempt under Section B&P.C. for this reason
N
O N Date Signature of Owner
rn
FL Q WORKER'S COMPENSATION DECLARATION
LO o z I hereby affirm under penalty of perjury one of the following declarations:
O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q () ( I have and will maintain workers' compensation insurance, as required by
O U Section 3700 of the Labor Code, for the performance of the work for which this
d 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
< (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
3 subject to th Sorkers' compensation provisions of S�ect'on 3700 of the Labor
de, Ir"sb�lf;f6rtYi.ithaeomply�wlPttN,thoelp
rov'.s�ns/
y ate: APPlicar -� , -«°°'
Warning: Failure to secure Workers' Compe sation 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
4 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
�1 any permit issued as a result of this applicaton agrees to, & shall, indemnify
map & 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. V
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
construction, and hereby authorize representatives of this City to enter upon
Ze above-mentioned property inspection//pur rises.
/ignature (Owner /Agent) r w Date��
r
PERMIT# I CONTROL#per
BUILDINGVALUATION PERMIT
_-�,--. 807-270
TRACT
DATE
DATE
2�S.�q3ioB .
ADDRESS 79-079 MSHL;+ �.' PLAC.'E
APN �/� 75-011
OWNER
CONTRACTOR/DESIGNER/ENGINEER
GEiNI`�1iMC1��>t�lFLl;.t-'Oh l�rU'1�11T1
CF.,N1iJRYC'R.OWE111,C..C33vt`Cl UNr[TrS
153 SO., "iD" STIU,FT, S'1`E
1535 SO. "17 S:t`ft;p'mr, s 1'L. 0200
SAN B RN.A.RO1N0 . Cts 92408
SAN URN.ARDINO CA 92408
(909)-%t-6007 CBL# 21,20
USE OF PERMIT
Si cU FAh iLY 1WRI.L.iIvG
SRU, 1"°i:.�W7 2ER , LOT 11, PEP -441`1` DMS NOT t"? CLU E BLOCK WALLS
0R POOL, Pr.XN CM (',i;. FREE ROXICEQ HY 75% FOR MULTIPLE ISSU&NC E
OF SAME PLAN YPR
3.Tc.V17 i ON 13i7RUC ION Sf.
F C Stt"`.E� �S'F
�ytaAM€ny'p ry 33�6.00
L%Ai}.A(JFai,�!)P . V'.RT 6. 700 til'
F+ -S INIA`1 ED COST OF COivSTR11CITIQN
FE.RNIX :: RE, SUMMARY
PLAN r'MCK 1+' . 101-00&4*9-:318 $115.84
(`ON$?'I`�.1JCT*(0N, FFF t 0l -000-415-000 3554.00
WKCRANICAL rTE 101=000-421-000 $47.00
ELF'€'FRIC:.AL FEE 101-0010-4211-000 SH".66
Pd IJMBIFif; FEE,, 1131-000-419-000 p118.00
SI!RONGY MO': MN 1i.fy. - RESID 101-000-241-000 X68.04
GRALMO F8F_ 101-000-423-000 $20.00
I3vTi1;A,Ia�32C}C1'CTt�iF�`£ Z2�5-fl00-�I�t3-3.1Z. Si.79�.y.1
u
t
a
'
'tll,
( 3 i OMK!'!RUCrION AND PI�N1 CHECK,
$2,2'„n.li2
LESS PKE-PAID �'. 5
X0.00
f SEP'•.`+-� 1VV� a
- TOTAL PE.Rhiff FE1" S DUE NOW
&2,766.52
LW
t S3
RECEIPT
DATE
BY.
D F LE
INSPECTOR
1 -1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _
/
Underground Ducts
Ducts
Slab Grade
�� -B�j —gam .�
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap!'2
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
22
Drywall - Int. Lath
Q
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
/o �� Q y %. %
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)
011 94