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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:
691684 i3 7; Go
✓Datej�� Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.
(,r) 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.
STATE 17UND 149093'4 47
(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 S ction 3,700 of the Labor
Code, Ishail fo with com I with dly}; rove ons
Date: I 4 Applicant �l 7 �,V_7'�_
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 A.
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"'
the above-mentioned property for inspectio pur ses.
%�. /jf i.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT »tf��9S�` CONTROL#
DATE VALUATION %J 2(J464"7,4) LOT TRACT 14-143
JOB SITE
ADDRESS u7 -NOS.�k���i�ll��'9'L1!►M
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
, f1111.0)1111CRO.
1 :C'J #ta"4siSw.'C),Ii;3
1292 1W..t\itRO frVVl
12821''W.ARROW MY
UPLAND CA 44785
UPI,AN13 CA 91185
-
f 7a9N,1-FS9�ey C131W41 3318
USE OF PERMIT
SI�il3i..E FIMUILY O`114EL[.ING
Sr -D, LOT R, 20. PLAN Qk , PMMIT DOES NUI- ifi(N. DS sSLOCK WALL
OR POOL. ,. PL.AN CHECK F03 i' EEWC;.ED 13Y '7."19 PO i..K41LI IVIPM 1SSUANC
'iIZ kCP CONSTRUCTION 24008.00 SF
I'ORCIVIM 1'1CI 14.00 5.a
C8Al2.ACJJYCAJd'01R:£ SHOO St"
ESTMAT M CONT OF CONST RUCI'ION
120,647.40
ft, RMUC FE ri, SUMMARY
0X4.i-1`R JC`ri(. '4 F 101. 000-43.8AAJ �1.13.ilCr
PI ANClIrC1%1°1 t01 #3{)(3a;; .t1R $t'�►i,74)
NIECTIANICAL ME 101.-000-4121-000 xsi7.411
ELECTRICAL FEE 101 •W0.4x(3-0430 $ i3t1.J4
PLUMBiN(:1IrL H 101-000-419-000 SI4S.i+U
S''RONO'I40TIONN ' E-RESIn 101-000-241-000 Sit -06
GRADING rFr, 101 -OW -423-000 52 .0100
Ii F'RA 3TRUC3"URU FEE 2225-000-443-312 SZ 710-M
ARTJN }31iMIC PLAC S - RESIC 701-000-2.SS-001 $51.62
-
4
DEC 3� � I, t:'f�NSER.i1G`TON AND FLAN CHFCK
$3,990.129.
Ess PRE -PAID FEES
$0,00
...--- r �- ..�_ - •—. - .. _ :E'EN` K.1. 8" SS.0.A,101cd .R FEES ES D4 E N47,'�'
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RECEIPT
DATE^
BY t`1
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Retum Air
Steel_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_
3�
F.A.U.
Framing
Insulation ��=Jz�,�
Compressor
Vents
Fireplace P. �/��-/�
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
f
POOLS - SPAS
BLOCKWALL APPROV LS
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
O.K. for Finish Plaster
Sewer Lateral
YYn_
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
c
Final
Utility Notice (Perm)
7/�