9808-198 (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
25414 7131.100
4��Signature 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 Policy No.
rlu'r;`a1`:Ei WA14 DO. Co. E3R'C Rit#' t1 -AVU. '
(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 forthwith comply with those provisions.
�D°ate: 1✓ z ?- ;tel-Applicant_Z'".l-.
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 it�fa;
whose request and for whose benefit work is=performed under or pursuant for �,
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
11
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. `
7 1, ,
ySignature (Owner/Agent) 1111K Date
BUILDING PERMIT PERMITCONTROL#
.
DATE VALUATION �"2?q�.1'Z.,61j LOT cf TRACT 1.85!1.5 8
JOB SITe
ADDRESS r 9,652:�.eMla'A
APN 7694 700-606
OWNER
CONTRACTOR / DESIGNERNfGINEleEi'R
Zv1,-sritto'ttsyyAAo ury
L J•.
SE
4pTE71.11
5 PARK PLAZA 9:1'E 400
5 PAII.1'1 iVA, SUf rk' 400
t.�tl' NE CA, 9261.4
MINE CA 92614
('1�13?.I-cit C13x,trl 1072
USE OF PERMIT
SINGLE FAMILY fli,1rE't,,UNG
,
L€7T# �, JEWIT DOES.NOT MCLCl13E k3:1.00K WALL OR
SF'D - 1A.1
V430L..PLAN Cti"F..CK f1;C R€,Ot10F. f) 75°/v FFR Ni(q`, lPLE f8SUAXC'6 O
YSAiE i.PLAN Ti'PE.
t„ W TON1 CON1 1411 R CTiON 3,072.00 2.00 Sr
PORCH/1.'ATIO 302.00 S
`3ARAW4:.A1tE-rXVIV 907.00. F
US°1':CMAWD COST. OF C-M&fRgtMION1
259,142.0
PERMMVEIIJI, SUMMARY
C0NS1`1WC:1'10N.FIE 101-000-418-000 $1,w9.s0
PLAN f 'R_ FCS. FV5 101-000-439-318 $242.861.
MACii.ANIC AL I 01-t?f)Q-421.000 s9S.50
F:L C*fRfCAL nTE 101-000.420-€00
PLUMBING M 101-000-419-000
S'1'r' (SNC N!t)voN r-hE - Rrmonn 161 -00 -241 -NO $255.91
GRAD.M0 f713E 101-000-42' 000 V1?0.1?6
MrlukSTRUC`1 MITTE 225,000-443.342 $5,740.34
Akf tOPUBLiC PLACES - RE SJD 701-000-25'"00 9397.86
� n1
} E
SlJWTMA , COINIMUC'[' ON AVT PLAN CREEK
$8,081.63
► 4 LESS PIU D PEES
$0.00
NOV 12 1998 TOTAL PIMMIT PER!6S 00FNOW
$ti,410.63
RECEIPT'
DATE4 BY /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
Retum Air
Steel
_
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
-
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final - 6 -
Final
- Gv
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
-
Appliances
-
Final
COMMENTS:
Final
Utility Notice (Gas) oej 11-1
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
t
Final .
Wtility Notice (Perm) _=eye