0312-023 (SFD)H
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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
.-6,.14187+
Date r` 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 STATE Policy No. 168$363.02
(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.
,.-Date: Applicant—
Warning:
pplicant 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( ,o
any permit issued as a result of this applicaton agrees to, & shall, indemGif'Jt
& 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 voi if
work is not commenced within 180 days from date of issuance of sch
permit, or cessation of work for 180 days will subject permit to cancellati - n.
I certify that I have read this application and state that the above informatio Is
correct. I agree to comply with all City, and State laws relating,nto the build g_
construction, and hereby authorize representatives of this City `to enter upon
the above-mentioned property for inspection purposes.
,`Signature (Owner/Agent) ILZl / — Date f d�
BUILDING PERMIT PERMIT#0$12-023
DATE VALUATION LOT TRACT
39 28961
JOB SITE
APN
ADDRESS 80-869
775-O('S12-012
OWNER
CONTRACTOR/ DESIGNER/ (NEER
Cry: QVniTr0, i�
x�acauJ°s: Fz;°��r C0MM0;,C.
200 � �.' M_'l�iP.�YGT0 Ate?, `TV 100
200 P �Az'�E43C�T.�N A.1Fi- 6100
E Cq 51uQ CA 92025
rSC101(', MO Ct%, 92025
050)639.8238 CEW. 5413
USE OF PERMIT
SFD e LOT 39, PLAN SAIL PERMIT I OrS NOT 114C).7JDE BLOCC
WALLS, POOL., SPA OR ORWWAY APPfIOAE-14.75% REDUCTION TO PLAN
C;H1:GK PFY, IDUE, TO MULTIPLE ISSU.A:I"IC:E OF SAME PLAN TYPE
CUSTOM CONSTRUCTION 31493.00 SF
POitCi 11P. ,1410 '148.00 SF
GARACIF'fC'ARPORT 650.00 9F
ESTIMATED COS ' O'c� CO.�&.1R UC'i'ION
294 55'40
qty r� �, /��rir+ Ari-�s lcpA AYES
.A' Y 14.F.i'A.f :i, (. Y I eJ.Iv6JYd.t� R E
CONSTI1.UCTION ,FTE 101-000-438-600 $1,322.00
PL,,A:N C lgECX PRY, 101-900-439-318 $269.62
MECHAIN ICA,L FteR 101-000.421.000 5143,50
ELEC'i'FE't!,"•.AL ME 101-000-420-000 5210.28
PL;Ulvlk) HO PEE 101-000-419-000 $179.25
STRUNCI ,MOTION FSE - Rf? SIEt 401-000-241-00.0 $29.46
OR-AD0140 F_P E 101=000.423.000 515,00
17L,/T?WP�:kt IMPACT FEE $2,405.1?0
.0T IN PUBLIC PLAC&I - RESIT 270-UOO-445.000 $236,511
C,AL CONSMUC°iIM14 AND FLAW C1ff?f_K
$4,810.61
�.a LESS 1' I>PAID MW ,`.1'
$0.00
JAN 0 9 2 04 (I T10TAL YMit`P. T 14 uSs fil DUP N()W
$4,01OZ-1
CITY �.•+y.a- •3txW'd'A /
f=fi�,�t�� � x•44% ✓/
RECEIPT
DATE
BYDAT
7 ED
INSP(E�/(�7'-O r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
— Z—D%'
Return Air
Steel
Combustion Air
Roof Deck
3o Q
Exhaust Fans
O.K. to Wrap
Z pV
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 - I . Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main rain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
v
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
Zp'
Gas Test
Appliances
Final
COM NTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp, Power Pale
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)