0011-267 (SFD)In
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'' 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
e 714 188, B 1013117K
ate fly '' 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 'j. 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:
Carr1;ier k.1? FA01,91NO Policy No. C„54406$-07
(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
Cdd' e, I shall/forthwith comply with those provisions. � �,rr-
JKate:— =`"—" Applicant ' %✓ �� ro�'*�i e . 17 e Y?
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^ se't 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
the Sbove-mentioned property for inspection purposes. 11 {
4Signature (Owner/Agent) I ` �� 1*d. �-' Date;_
BUILDING PERMIT PERMIT#
0011-267
DATE VALUATION LOT TRACT
i
2V 19JOB
SITE
APN
ADDRESS
76,9470-022
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CM411 kSC CROWTV:. CC`M.mu),grfM11 -
C.F.91URY CROWZ2. CO.A9.LMUNM.Y8
33,5 so. "fyJpq��gyro �'T1 �iix.. #7/ o ,
53�g5 so, '7�?°�:y�'�4 La. a'�.+1�{ 02100
{ice' y �y
s7./1LV EW'4'.f°�F'47. INO \.µ4k 9240Ca
q1
�' ,y �b
i7.Tl�FV BZWAR1 .Jf00 C�"� 91:�408
,909)381'•6007 CB110 2120
USE OF PERMIT
LOT 50, PUN 211; SYD - P1r.MIT DOES NOT iNCL.UDE 8111OCX'iWALtS,
g'0.4 OR DRIVF 3AY,APPROACH. PIAN CHECK ft'F. k1EDUCF(D 7.W,� P)0R,
ASS'ULTIP11F, ISSUANCE-- d SA M11r i>1..AR4 TYPK
0,68TOM OAA CONSTRUCTION ZS97.DO OF
POI?CRIPATIQ, i 21100 sr
dARAMOA13.P4`iRT (811) 11,858,00
ESTIMATED Covr OF C-0 N9TRTJC]l1r0H
AMM1190
I'ERMrf TER STAVa"Ry
CO'NSTRUCT10-9 Imo' 101.000.418.000 $1,1149.00
PL, i CHECK FFIF, 111-000.439-318 $212,26
MWYMITICAL LER 101.000-421-000 $91,00
9LECT€tIC'Ai.. F91 10 -00(."-42(%1}00 $144.00
PLUMMBINO FER 101.00-419-000 5168.50
STR,ONO MOTION ME - RZSXD 101-000-141-000 521.7 D
c3k.AFJIN0 ME SX00.
DEVELOPER IMPACT FEW $3.,9Id'?.00
, kT TR PUBLIC PLACES - Wit 701»000-155•IJOO 442.46
aq
pEC 1 � ,q°'WTA� . c;ORSUMMON AND 1 C701,0K .
$3,615.92
1'.x.5 :P1:t1•PA3D 17013
$0.00
"E`OTAL
MMM M 5 M NOW
0,05,92
' t
RECEIPT
DATE
BY
DP�E�F
INSPECTOR
�L Q
1(Jl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &Footings
/ �0
Underground Ducts
Slab Grade
�'p,�
Return Air
Steel
_
Combustion Air
Roof DeckExhaust
O.K. to Wrap
Framing
_��
�� _�
_
�—
Fans
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
Final
— G'
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footin s
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
/
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
� Q�
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
Utility Notice (Perm)