9908-190 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed Under provisions of
"Napt�r 9 (commencing with, Section 7000) of Divisn,3 f t1h Busin s and
I"Profossionais Code, and my License is in full force and effect.
License/ Lic. Class Exp. te
MOM
ZZ*11. a
ate f�signature of Contraqtor,_--��/
7 71 �,77
I hereby affirm under penalty of perjury that I am exempt from the Contrbictors
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 offer I ed for
sale (Sec. 7044, Business & Professionals Code). ,
_(, ) 1, 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.
(,4 1 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.
S"A AM 117VINT) 1: 1*4 Yt *1 1 - rvd: �11
(This section need not be completed if the permit valuation is for $100.00 or less).
his permit is issued,
I certify that in the performance of the work fo whichr
9 /
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree4hat/if I should become
subj to the wor ers' compensation provisio, so ectidin 3700 of the Labor
C e Is ith-comply with those VI 10
t 7
/e
C e I sb6ll fort ecil
at-- Applicant-.--..
Warning: Failure to secure Vtq�_kers' Compensation cove ge 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 v ' oid 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 canc'ell�tion.
I
I certify that I have read this application and state that the above in rm4tion is
correct. I agree to comply with all City, and State laws relating t( �the," uilding
consjruction, and hereby authorize representatives of this City to.. e, ter upon
t
th bove-mentioned property �pr inspeqfion purposes.
'V rignature (Owner/Agent) D.bte—
BUILDING PERMIT
DATE ak-M" VALUATION LOT
JOB SITE
ADDRESS =4Z AV04M SUMIDAS
OWNER
ANUA FAMR-AVINUJOHN SiLVA
USE OF PERMIT
SNOU- IVAMOA- bWPLUNG
9"6411111111;
TRACT' �
APN 7794P&M
CONTRACTOR / DESIGNER / ENGINEER
PM OR= CONSKMUMON INC
766 53 (-ALIFORN 1A DR.
PALM DESERT (A. -W-211
(76004'%4IN (.13LN i"t
SFD - P&qhfiT LA:Pfi ic N6T INCLUDE 11L(kK WALLS OR
TRACT �XJNXMtk7nON 1.1,28.00 �w
11140RCLWATIQ 451.00 8F
0ARAi*A*,ARy(*,r 432.OU 3F
=11.2,11I.TrD (03T OF CON.T.M..'(7,
10N,
M.M.
PKRMiT FLY, SUMMARV
'_X_ftS11t1K�,noN P,a, 1014)1)0-4184XK)
$671.00
P1 AN (IWC*K FFF IA14W-4V)319
$%? "
MT D13N.)51T 101 -OW -439L-318
_32W.00
4
N&CHAW,AL FISIB 101 1004214)00
S53.30
MEC-MICAL FhE 101 -000-420-OW
sin 2
1131,11 ?W"40 FPV
S143
,TIRONG WMON IT)-*. RE.3111) 101-00G-241-000
$10.93
GRAIA NO FFE 101-000-423-000
S20.00
PRhC18F PLAN 101-000-441-1W5
$100.00
ART IN lyll 1KfC PI,A('" - RV31F. 701 -(XX)-25V�401
%�411 74
DEXLIOPER UPACT rr-T,,
$1,907.00
S1 mm Tr.� I � ('O.Wrl 'R H(TION AND PT,A N CHK -K,
4
LFSS PRE PAID FEES
S250 00
TOTAL PVRMI*f FEES DUF NOW
U,3115.42
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE -TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
om
Ducts
Slab Grade
V* 10'ef
Return Air
-Z-i
Steel
Combustion Air
Root Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
ap e IF
Vents
Fireplace P.L.
G ' rills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
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
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
CO ENTS:
pe4oems 0s._r .1. log
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.1,
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)