0312-025 (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
763187 B Sri 1/0s
Date �` f/, 141 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.
N ) 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 & ArE FUNjD Policy No. 1$811243-p2
(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:.,,/f T
Date: r 7 / 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. t .
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 -indemnity--'
& hold harmless the City of La Quinta, its officers, agents and employees.1
2. Any permit issued as a result of this application becomes null anMvoid if
work is not commenced within 180 days from date of issuance�4, such
permit, or cessation of work for 180 days will subject permit to can, cel�ation41A
I certify that I have read this application and state that the above inf, rmattiion is
correct. I agree to comply with all City, and State laws relating.to tie bulldi�g�
construction, and hereby authorize representatives of this City to; nter� upon�li
the above-mentioned property for inspection ppur'rposes.
Signature (Owner/Agent) //.-�/�� 1-� ` r Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' TRACT
JOB SITE
ADDRESS 811 -90.1 10FLIYA n
APN
77.5-W,014
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MV LA QtWrA 70, LP
INNO m ml�, t�ESop CC.tmmliNnIES, iNe.
2000 WAIal GTON ,AW. STE, 100
200 E. W0111WarrON M, Ih 00
' Cok1 mo Eat► 92025
1+.SCONT,3273C3 CA 92025
(760)8394238 C1 P, 5413
y ,,
USE OF PERMIT•
I
31114(,le, RAMILL JY+c•_7W1.:
u tl �.1:.OT 41, PLAN 2C.R.. PERMIT :DOES NOT INCLUt]E $LOCK
WALLA P0014 SPA OR DRN1wV AY APPROACH, 73% REDUCTIONTO PLAN
CINECK FEE 'DUE Tt1MULTIPLE ISSUANCE OF SA4.ME PLAN TYPE
CUSTOM CONSTR.UCTIO11 3,48$,00 SF
PORCHIPATIO: "A8.001 SF ,
CATIAONCARPOWl' 600.00 SP
ESIThUT C 083,' Otr C;ON61RAJMION
294,5S*,f )
(MrMiTRUC'.TION F1±E 101-000418-000 $S,•sd2.00
PL,AiU CHECK kZE 101.000-439-318 $269.62
MECN.ANICAL M 101.000.421.000 $143,30
`u.L ECTP1Cr°',1. FEE 101-000•420-000 $110.38
PLUMBING FEY 101-000-419-000 $17912.1
STRONG MOTIrM ME - k 91D 10) -000-2413 000 $29.46
OR.A DING FEE 101-000-423-000 $15.00
DEVELOPER IMPACT FEE $,405.00
.AWf 1N PUBLIC PL&CES - RESIr 270.000-445.000 $6301,50
S-TCSTAT. CONFIR.TYC°i.:CC)N AIM PLAW C BECXC
$4,810.611
i . LESS PRE-FAW FEM
50100
TOTAL, P01 RhW Y-MISKMINOW
09 '1104
.y... :}t.,, rA
4iv
RECEIPT
DATE4
;'
BY
�
DAT �? D
INSP R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 71_
Ducts
Slab Gradej
O`
Return Air
Steel
_
Combustion Air
Roof Deck
G
Exhaust Fans
O.K. to Wrap
Z
F.A.U.
Framing
p
Compressor
Insulation
/ p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
?�
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service L17 T I–
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: r�