9910-062 (SFD)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 4im 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
.690645 B ~s 0036P210f
Date �� �� 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 V the- Labor Code, for the
performance of the work for which this permit is issued.
(� 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.
(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 /f,,S'ection 3700 of the Labor
Code", I sha f fo with comply with those lofts.
Pate: %[A��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.
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 represe taJt3es of this City to enter.upon
the above-mentioned property for in pecti�purposes.
V ignature (Owner/Agent) " Date /0�
PERMIT #
BUILDING PERMIT 99104)62
DATE t ( (,( VALUATION f16K�" LOT 41 TRACT 2,51-414
ADDRESS r��^9�Cn?Si� �Gl�T^I�,e�il. �� �� JOB SITE
APN
OWNER
. , CONTRACTOR/ DESIGNER/ ENGINEER
jturn 1N S1 rfL�-s, BeC. 01. INAV}_4,Fy hl FINI,17f, F htC.
. .
-1425 E.11NAV'ERS1'IT ' 1X1"v1:; 1425 E. t,rk�j,�lt�➢�.SUY'DRIVE
1'.ROVfV X AZ 650M V,140ENH;;.t AZ 85034
(isf➢2)'.574s656 CT► A 4990
USE OF PERMIT
SINGLE :N-ARLY l l °L9.,1NCS
SH13- LOT 42, PLAN A. IMMI DOES WT MI. IDE BLOCK WALL 4 .R
NCXA..
415TOM i:ONVS C`�,7 �wTXON 1004M s%
i TRAM 1411010
43A :.:?.;
C6As�C;P1; t� jdt 3.3i.`,f
daf ifli Ski'
.' m'g�T&IMXUD Mff € F CONSTRUCTION
7f-.���di474�.ft k�,t&RYVS�Y:SS'�i.f'�,�'t 1F
C:0t\iS'TRXJi✓'r10N'FEI-E
101.0W-4P;4,,0(k
SO4.100
R. j 7 CWCK FEE:
301-0ft(t4"W-319
11 115.74
P.41:C'f,1AMc:tE?:1•'€1�
I0 R -fn-4211 n - W.9
U10.00
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Si t�ic�Art�>!•fc1N'1'f - .r,,�x?
1,01 -OM X49 ►
SIS(
ORAfliNG GEM
101.400421(3Q o
$20-00
'
MVELOPER ezdtPAC a T. -k i
!►,6,W.7.00
ART i.N E'1d9311(" Pj:.ACE S -, Sth"Sir, 701-000-255-40
1fii4UB 90 AL{.;0N e`,+FAl,U !1()N AND PLAN C'1:i FCAli. 144,062. 10
TOTAIx PERMIT FEES DUE NMW $4,062.10
RECEIPT DATE BYf I �' DLED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Zo'
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap
Framing
F.A.U.
Compressor
Insulation
ALVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
�� •- C� G�
Final
J— 5 w
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
I
Gas Piping
-
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
U '
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
L tic!L
Appliances
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)