9807-274 (SFD)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.
C,) + License # Lic. Class Exp. Date
LO
� Z I-- /at��_/ZZFSignatureof Contractor.
000 /
J tp OWNER -BUILDER DECLARATION
HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
(n 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).
ce) () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
O13-
Q Z I hereby affirm under penalty of perjury one of the following declarations:
F- p () 1 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.
CD Q U ( I have and will maintain workers' compensation insurance, as required by
O CJ Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier Policy No.
cb O G01, 1 YE N 1"sA:GL21N'O'. ,~ WC 54406S-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 the wor ers' compensation -prove f`p sZf S df on 3700 of the Labor
Colie. ds all omply with th se ' islon
ate: /� Applicant
Vol 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
construction, and hereby authorize representatives of this City to enter upo'n
theflarbove-mentioned property fo 'nsp.ection drposes. %
'Signature (Owner/Agent) %� s'Y` y' �+ Date
PERMIT# — CONTROL#
BUILDING PERMIT 9131,7.214
DATE VALUATION Sim7fa,40 LOT —1'; �I TRACT 71
OB SITI!r
ADDRESS ! - ll� iAw�/%�) r et �i..�
APN 604-374-007
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C",11h MkYC°Or�ELLcoN-11M NrillLIS
>:r:r�c'ra�� ���s�.�>`:0�� �rnj-r��:s
1535 SO. „Dw "1 ltk:l .F', � FE,; W200
1515 SC?. "G" fif ` IRI E i, 19ir . s#200
SAN 1 ERMARDINO CA 92408
`.A.N.lBERNAkDINO CA 924OR
�9f1 p 1-(007 CK14 ;2120
USE OF PERMIT
S1A1t,i;,E .1?J� ittllUY D"Li:r•j.Nt_i
WALLS OR POOL- PLAN CH sC.k VW,, RFOUC:.E D ,WY 75°•0 :E Ok A9t.t1-, TPL;f
fSS1JANCT: OF SAME PLAN TYPE-
'1'1L iU71.' CONSTRUC 1 ION 7,O1f) X30 .`w
GARAWCtiftisOKC 389.00 8
F31T��X L,.€S COST Or, CONIST':t:UCfXON
116,7 67.40
CONS'1RU 'JON F1 101.-�i){?-418-000 S�t�.�AXJI
P!, AN CHEC1C.FFM 101-000-4314-319 S14655
1ARC ILANICAL IM 101.-000-421-000 $470) ,
UEC"P1tICAL FEE 101 430-d20-OC,O $126.63
f'f.[;MINO,iPL7E 101-000-41M00 51.72.00
-'ONO MOTION FEY, - R- SID 101 -00f? -241-4M
U11W1NG• 1`iM iol-000-12:3-000 $70.00
1Nx 12AS RUC;TUPZ- FEE 225-000-443-342 &2,627.27
ART IN PULA .iC PLACCES •-Rk,SI , 701-Q(}}0 255-000 t4d.9
7
,:. C ONSTR r�"i' ON AND PLAN CHECK
$3,892.05
,AL
LESS PRE -PAID FEES
$0.00
SEP 2 l:...v TO TXI, PE.rtM>i r FEL, S D U K NOVY
Ry CEIPT,:_
DATE
BY
DAT FINA D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs/
Forms & Footings
3� ��
Underground Ducts
Ducts
Slab Grade
_
ja/ -01 —Q
Return Air
Steel
Combustion Air
Roof Deck
it; — 7- k
Exhaust Fans
O.K to Wrap
2-2`j—
F.A.U.
Framing ,�>D ti
Compressor
Insulation
//0'L /
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
_/�� _
OWN
Final 3A
'POOLS
BLOCKWALL APPROVALS
Final
-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�o-
Water Piping
_Q /
(
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
(o -,?o _ �'
Encapsulation
Gas Piping
Gas Test
Appliances
_ /
�-���
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbitures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
E
Final -
Utility Notice (Perm)