0401-037 (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
746198 !3::1' :C.'
Date . Signature of Contractto
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 STATE FUND . Policy No. 046-010009232-02
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of tlpe 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 rovisions of Sec�lion 3700 of -the Labor
Code, I shall forth comply with those provisions.
,,Date: �•��� Applicant 71,
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 City, and State laws relating to the building
construction, and hereby autho:i a representatives of this City to enter upon
ned
the above-mentiopropel Zr inspection purposes `
Sig lure (Owner/Agent) (7� Date 1
BUILDING "PERMIT PERMIT#
DATE / VALUATION LOT15 TRACT U1 9 BL.K 70JOB SITE '
ADDRESS 51-l.i?r� A�"@:i��tDA HI '1�a.&�1t;R A. APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
A & M 1:10ME BUiCZ1 .I1.0 A& M C0NS7yU{.4*rs0W
;76.070 CALLE CADJZ 78-0'70 C—AUE CA•C:(Z
I—A QTWfA 0A 9 :2,53 LA QUXI'A CP. 92253
(760)3644832 M9 626
USE OF PERMIT
SINGLE RAMILY DWF,,IAffNG
1721 Sly SVD. PERMIT DOES NOT INCLUDE POOI SPA OR BLOCK
WALIS. DRIVEWAY APPROACH RIQLIRM A SEPERATE PERMIT AND
INSPE+'C`YIGN .BY PUBLIC NCIRK:S I EP.ARTMIXNT.200I CDC;.
T kACT CONSTRUCTION '11781.00 SIS
PORCHWli 'r10 56.00 SF
GAPA61FXARPORT 503,00 8P
Ei91 MATF0 C087 Or S.t?N£417MMON
10713151110
1'3,RJWI C NIM ST7I1!#;WARY
CONSTRUCTION AEE 101-000-418.000 $667,50
PLAN CHECK FEE 101-000-439-318 $553.00
PEE DEPOSIT 101.000.439.318 -$250,00
,
MECHANICAL CSI•.!: 1011 -000 -421 -WO $160.011
ELECTIU CAL PRE 101-000-420-000 S120-04
PLUMSfNIQ F7°.1; 101-000-415-000 $130.00
STRONG MOTIOA YEL - RE SID 101-000.241-000 $10.74
ClRADMICI FEE 101-000-423-000 $13.00
DEVELOPER IMPACT FEE, a"2409,00
f
PRECISZ PLAN 101-000-441-345 $100.00
SUB -TOTAL COIdM.L1'C 11023' AND PLAN CIM.M
LESS PRE -PAID FRES
-`0250.00
r D n '1"O ' , YERMT YM DUE NOW
2 0 2004
.IAN
`
CITY OF LA QUIPITA V
ctmikmnE DEPT.
AN
iECEIPT
BY
DATE FINALED
''�/ CJ f.
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
——
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return 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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
xr-
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- _ Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer ConnectionC
Pool Cover
Encapsulation
Gas Piping
_
Gas Test
= e
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) J��O•�
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
Utility Notice (Perm)