9809-235 (SFD)FI
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 .r + Exp. Date
vDate / 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 Policy No.
.,1'F- TE �" N -D 01,16-98 ;,'T 0-139
(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 Calif orn a,,and agree that if I•shguld become
su Iect to the workers' compensation provisions 00°ns of Section 37of ,he Labor
I6ze, I shall forthwith comply with those provisions ""`t?'`�
ate: AL. l •f""O Applicant t �"� ,.fid
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. Gagree to comply with all City, and S.t�ate laws relating to the building
constr4ctlon, and hereby authorize representatives of this City to enterpupon
�th bove-mentioned property for inspection purposes.
Signature (Owner/Agent) Date -F
BUILDING PERMIT PERM'9X0y235 °°"TR/°�[`#
DATE VALUATION S2fi1D,917,.2lD LOT 37 TRACT •�V�1J 1 Q
V1JiV
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ADDRESS I JOB SITE' P-�I& Cr�A�r�f�I4if4
APN bAZ-g�.�}��.1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MID
P1.B 0.111, i 716
79-295 t2Ar,+1MO L,A CWNM UK.
LAQUI N'1'A CA 92753.
LA QUINT A. CA 92253
r'7t�(1�771.19�11 C431;,# �9•�
USE OF PERMIT
tifNt i.X FAMILY 3.3M23LUNG
00,. PLAN MA. (MO& L;) U9`T 33, li'1i'rtf41;1T'DOES NOT 31*1t"..1.0 1, R. LOCK
WALL OR POOL,. PJ..AN C° ECK FEE RIVA)LICi D 75IN6.17OR M.UI.'F.1 111
ISSUANCE OF SWE, P.taA YTYPE.
i:.1r9u' OIN4 CONS'T I1.iYMON 3,076.00 11111:
P0RC1:U'i kr1U 580,00 SF
GARA.(tFJCAftt+ORT 693.00 tit%
`i"INIA3TE1) COSH' OF MNS1':RifCTION'
Z.61i,`?n7.�il
I1VIR r FEE :4QJMMARY
CON'StRUC;.-10N FEE •10)._000.418 -Wo $L12f)3.00
KANCHECK F'.faf, 101-M -439-3118 ' g^47.07
1411 CFLWC.AL IEE 1.0.1•-000.421-000 $1.21.00
SL':l C:`MCAC•.RE
Pl..tlNIB[No FEE 101-000-419-000 SLS:?.00
'S'R.i3?VCsmum ti ir.-r-x-hitt') M-WO.24I±-000 $26.09
GMAr)t1mL1 FCC 101-000423-000 S9a.00
f1SFRA SZ'Ri1t: t {1RL, F E 225-M-443-342 $5.07.07
ART EN TgJH[AC; PLACE -8 - 1t1 SIC 701 -NO -255-000 5402,29
8 +J., (Y)N8"1 R 1C,"rION AND PLAN Q FCK
X8,1 o-4
LIESS PRIX -PAID PUTS
$O. on
'IO`D"tAL PFI1'I'MIT F.H;IN 0U1 NC9 V
%S,:I.0&o4
REE IP7 `
DATE -?BY
DATE LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
! MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade
f�— - �j
Return Air i
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulations
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
w
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final =lL�
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
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
( l�
Pool Cover
Sewer Connection
4�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
(Gas)
t
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
i
c
Final
t H14 Notice (Perm)
_