9808-205 (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
� 4
72542AI '713 U00
,/Date
//-",? -.i } Signature of Contractorf
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, f6ir the
performance of the work for which this permit is issued.
(,X) 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.
AiwMCGAN 110, CO. i'Ja T is toy
(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.
EDate: Applicant
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 upon
/Signature
above-mentioned propertyforinspection purposes. /
'Signature (Owner/Agent)L` ��'' Date//2-
BUILDING PERMIT Date///2-
PERMIT CONTROL#//��
p
DATE VALUATION 289, U A0 LOT 40 TRACT �Q;.�,h 5
wY 6 5
11/17.6
ADDRESS i'-a!D a7i3.iiU JOB SITO
APN 769-700-020
OWNER
CONTRACTOR/DESIGNER/ENGINEER
f',1HSF'ft7 140 SD]Gsr Ll
C.A.'i'E1. L S RESIDEINTI'1A1., CONSTRUC TICINT
.
a :inti? I1 PLAZA 611, 400
5 PARS. PI..A7..A, SUITE 400
MWNE C.A. 92614
IRVINE C;A 32614
( 714)251-6100 C13LN 5072
USE OF PERMIT
' S1.N ,1,R .tAI1MiLY rJVf.�'LLIN
41M) - licit -O i, LGT# 400 Kn i DOM NOT .INCLUDE ac')CK WA U
ONZ POOL. 1 NIN CHECK tt.ksDi:CH.D, 75% FOk MUL"TH"L:,s.ISSUANCE Cit
SA,NE h`'I.AN TV) X
C.'tJ.STO.N1, COIN STR IJP, T ON 3.411.00 SF
PORM-1/t'A'.f10 M2.00 Sia
(.; ARA,G'O:ACARt'(J12."4' 100.00 SF
ESIFIXTATED COST 01F CON'STRUCTITON
1'E;@Ptb'ITT FEE SUMMARY
C01NTi'RVC'fTON FfE 101-000-418-:000 $1,297.0
pwwc;tpm;..t' r 101-000-439-:315 =720
?14 'C1-WJ1CAi FLE SOO.-So
ELECTRICAL FM $220.33
PL01\03fNO F -b -E. 101-000-419•,000 $214.50
STRONG aIMO TION;F.ES ..16RS1D 101-000-241-000 $28.73
Q R.AI`71r G .,ME 101.000-423-000 �2tiA0
1NrRAST,R1 iCTURB l; i3: 225-W0443042
ART .(N f?13f31,1C' PI.AGP;.S - RE. sir, 70.)-ow-15S-Utm $468,36
,
µ .F
1' SLi�#'T('.A.r: CCNMfJC"nON NI) PIAN C14FC(!K.
Sf ,647.15
.., LESS PRE !'.� LD EFTS
V J �. !
NOV 12 1998 TOTALPr;RNlYf FEMS DIJUNOW
Rh ivS'
LIE 5 J :._b-
e � 1
r..
RECEIPT
DATE
eY
DATE FINALED
INSPECTOR
IN(
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- -�
Underground Ducts
Forms & Footings
C
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- '
Exhaust Fans
O.K. to Wrap
F.A.U.
G •.
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
Final
- c
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
— - (l
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
c
Final
_
Util►iy Notice (Perm) Cl