9807-276 (SFD)_ _ _- LICENSED CONTRACTOR DECLARATION
z� 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
WProfessionals Code, and my License is in full force and effect.
�; rift ]
License # L tLic. Class Exp. Date
1: 19
O Z � /Date Signature of Contractor
ro O.o
�p OWNER -BUILDER DECLARATION
W d I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
O CV
CL Z WORKER'S COMPENSATION DECLARATION
'It CD (r I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LIJ.� compensation, as provided for by Section 3700 of the Labor Code, for the
Om J Q performance of the work for which this permit is issued.
Q L) (y) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
rn permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
coo d GO D R EAGLE INS, ;3WC "4068-00
J (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 tt e workers' compensation p�s'ions D�Aection 3700 of the Labor
3 Code, dam' a�,fortd4th comply wl��e provisions.le
vDate:/� ✓3S Applicant !'ter
Warning: Failure to secure Workers' Comperfsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,00.0, 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'Z
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.,) agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propY,"�
rrfnspection purposes.
signature (Owner/Agent)EDate's
r
r
PERMIT# . ) CONTROL#
BUILDING PERMIT
9807.76
DATE„/,JVALUATION ��,� J J.0 LOT _ iT- TRACT 271 49
9
JOB SITE .
ADDRESS Jai-Ii0.t�.4il�, F*A. 1';
APN
OWNER
CONTRACTOR /DESIGNER /ENGINEER
�y1rYwV: iryVpi `
ES"HN(U�RV�E11JNqIXITyM
.
1535 So. coos STupr:lj. gm. 9200
1535 SO. "U" STREET, STE. #200
SAN BE NARDINO CA 92408
St�N BERNA10t),'iNO CA 92408
E;909�3Lt1 FS)n7 CBL # 2120
USE OF PERMIT
SN(I' aF FAMILY UVEL,L NG,
3.t i3, PLAN 2818 , .1 OT 17, 'PIRRMiT `>DOES 14CJJT INC.i ia_E }3.i.00K
LVAI.I,S Qit f:'(XJ:l...1y£.A'RT CIrl1�{: Fif,F 1)Uf�5:1;� i3y' �t<rro ;u'tj12, i�1i�a:r�1,�:.1~ '
ISSUAlUCtCIF SA;4%P11"T.''i TY -Pt.
TRACf CONS''ilcUC ION 1,11,5.00 S
410R.CfMIATIO 36.00 SF
<:A' A..Q&Ct4i2i'( fVf 630,00SF
KLAN C” W—XX f"Fi: 101-000-430-.315 $115119
C(,.)N$TIt111;T1oN, rn f.01 -000-418-(30f;
NME-CHANICAL KE 401-000.421-000 547.00
F..1.E,,CTRICAi. FEF 101 -000 -42.,0 -WO $141.68
101-000-419-000 SI18.00
5',['[tONO MOTION FERE Rrism 101-t1M-241-000 53.04
G.FtA nm I..1 li 101.000-/423-000 $W0.0u
TYv1"4i��431RUC1'Uk21<I'i � 225-00 0-443-342 $1,798.91
M7'N., CONS-I'.CtUCTION AND PLAN CSMC'.K
y l
LESS PRE' -PAID FEES
$0.30
SEP 2 t. �.� TOTA FRRMI ' 1~`i✓&$'lAyr1,N0W
.. n X.
REC1�IPT
DATE
BY'
DSE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ -
l 131-£
Underground Ducts
Ducts
Slab Grade
to - �-
Return Air
Steel
Combustion Air
Roof Deck
3
Exhaust Fans
O.K to'Wrap
—A'?
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
�a9
Final
Final
BLOCKWALL APPROVA S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
_ _
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
_
(O -.70 —9
Encapsulation
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
i
t
Final11
il "
Utility Notice (Perm) �'
COMMENTS: