0205-044 (SFD)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
Date ignature of Contractor
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 ISTATs ruND Policy No. )"152
(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
/Code�,/ I shall fo hwlth comply with th se.provisions.,� r '
Date. c! Applicant
Warning: Failure to secure-Wcrk s' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject. to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this applicatiomis made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the'above-mentioned pr(515erty for
innspection'purposes. /
Signature (Owner/Agent)-24k 4r� �-.�� r.� Datetr
BUILDING PERMIT PERM T#
4
W,03-044�
�//-,
DATE VALUATION LOT TRACT
- ...$.1"$48.2,U- pie fTi 5n
,
JOB SITE �
ADDRESS 77"020 LAWWO C'OUWI ..r
APN
773-022-021
OWNER
CONTRACTOR / DESIGNER / EN (NEER
40DONAHOS,11)C'
r cr�. Ct»:+KW11—LION
77 >(A C0LIM7.1 CLUB DRININ : 5I:'lii;137
7 7 - 64 5 A C:OL7N rf =07D DR.V "Yt%TIE150
PALM DMIRT CA. 92 ,11'PA1,M.1
DRET'
A W0260
X -
USE OF PERMIT
Sy'�k��'yiry? -LOT 4xx0��jyP1,AL��( Itry( T�1�QP�Jp%��+72y+1OT #kt£:�.UDE 1. L0ClC,'VJ:A7.,L
$i�'.�rJT'+�/ju?yI
�1 S,,0 4 i%PA? 1. Di�,LV is i7.C361, .G•F Y-}-'p�,4y.TX•A{118 D
.'
CUSTOM CONSTRUCTION 8236.00 N1'
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PG"FcCHIPATIO, 186.00 sw
0ARAOR WARP0RT .525, 00`8:7:'
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a . WCA.6.CSYf.Y CviJ4%'9. 08: �r'141.CMJC' A, AY
7.{DSYp
CONSTRUCTION ME 101.000.416. 00 $044.00
�"� -
MAN MNECK ME 101.000.4439-s 19 M90
111JGf C°11,4'NICAL "..$ 101-000 0121.000 801.00
ELECTRICAL FEE
PLUM811HO ME 101-t1�i�-41
S3'Fi:C'rXG ,M0 'iOt4 FES: = RiS D 101-060-241..000
(MADING FEE 1031. -000 -•423 -DOSS $20,00
DEVEL +PPM 1s+tP11 CT 1E'L+ $1,907.09LE
�.
P.M14FAR) FEW
1010.00
RECEIPT
DATE
DATEEFINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
`Z.� .
Ducts
Slab Grade
Return Air
1,7
Steel
y
Combustion Air
Roof Deck
_
Exhaust Fans
O.K to Wrap
— j
F.A.U.
Framing
Compressor
Insulation
— Z —
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
I 7572—T -
Final
' 2 --
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
Z — "'r 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
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 3
Utility Notice (Perm)