9907-480 (AR)LICENSED CONTRACTOR DECLARATION
1 -he ' r6by affirm under penalty of perjulry 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 Date
_"Q
ate ianature of Contra 6_�
OWNER -BUILDER
I hereby affirm under penalty of perjury that I am exempt from the Contractdr's
License Law for the following reason: ' I -
( ) 1, as owner of the property, or my employees with wages as -their sole
compensation, will do the work, and the structure is not.intencled or offered for
sale (Sec. 7044, Business &.Professionals Code).
( ) - 1, as owner of the property, am exclusively contracting with licen�ed
contractors to construct the project (Sec. M44, Business & Professionals
Code).
I am exempt under Section B&P.G. for this reason
Date' Signature of, Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following Aeclarations:
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.
have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for4e performance of the work for which this
permit is issued. My workers' Compensation insurance carrier & policy no: are:
Carrier Policy No.
STAIE V UNAD
(This section need not. be completed if the permit valuation is for $100.00 or less).
I certify'that in the performance of thew'ork for which this permit is is�uedj
I shall not employ any person in any manner so as to become subject�o the
workers' compensation laws of California andId-g—ree tfttt-�f I should become
subject to thp*worVers' compensation provisions'of Section 37,00 of the Labor
. / - '� �V
Code, 1'slyajl foqhwith-comply with thc(seror—�v`lsiqns. . _�;) I` "_ �1_ - ..
Warning: Failure to secure Workers' Com_pefisation coverage is unlawful an'
shall subject an employer to criminal penalties and civil fines up to $1 00,000,.i
addition to the'cost of compensation, damages as provided for in Section 370
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 app lication 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`St_a_te'1pws relating to the building
construction, and herebyeaUffibrize rerresentatives of this City to enter upon
the above-mentioned,property for, ih�pection pu '9�s
'(Po§
I . A
ignatu're Owner/Agen) _X;
Date
BUILDING PERMIT PERMIT #
DATE VALUATION $1458.00 LOT 13 TRACT 28640
JOB SITff APN
ADDRESS 79-60CALLF, BRISA. 649-2.10-M3
OWNER
T.D. DESEFF DFIVELOPM DIM
P.O. BOX MV6
LA QUINTA CA 922-53
USE OF PERMIT
KESIDEW1 -Wg
CONTRACTOR / DESIGNER / ENGINEER
SPARKS �ONSTRIJTCTION
79-795 ELANCI-10 U, QUINTA DR_
LA Q�ANTA CA 9PT53
(760)771-1-�441 CBL# 2996
'20,14F M)DITION TO WEST SILT47U, crtzot wjqN4ra.UCT boyl t%0T i�)
k
CUSTOM CONSI-MUCTI JOIN
FSTWIVINP1,17V COST Of CONISTRUMON
PERMIT Villip,80,MMARY
PLAN CHUCK FEX- 101_000439�318
CONEffRfy 11TON ITE 101-000-41RA00
ELEC70CAL FM J. 01 - M-41.10-000 V/10
TMON(.1 MP'OTION FEU� RE�HJ 101-00.0-241-ftl $.50
ART W PLY)BL.IC PLACES -RESID701-000-255-OW w;, 9
I I
SUB`(rJrA L. (70NMI UR',170N AN D PLAN CHT'CK SW i 5
LESS PKC -PAID PFES $0.00
TUEML PERMIT 'FEESDUENOW S66.15
RECEIPT I DATE I BY I I / I DATE FINALED IINSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
I DATE I
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Partv 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
I
Underground PIbg. Test
Final I
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Ublity Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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