9809-224 (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 # Lic9 Class Exp. Date
• N
elDate r� `' �-' Signature of Contractor--"-
f _
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 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).
( ) 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.
Se( •) I have and will maintain workers' compensation insurance, as required by
ction 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.
STATE FM4) talo -95 f7i4`! Ft?�+i3 P3�
(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 f�should become
su�j'e'ct to the workers' compensation of Section 37b0 of the Labor
Code, I shall 6orthwith comply with those provisions rr j
!/()ate:'/:) 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 3.706
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 represeritat vi es of this City to enter upon
the above-mentioned property for inspection=purposes.
ignature (Owner/Agent)..---•} / /r /,Date-"
Date �' r
PERMIT # CONTROL #
BUILDING PERMIT
Sf> 09-224
DATE VALUATION s�ti t, 3" �1� LOT 29 TRACT ��-315"
146 6
ADDRESS 79-065 CALIX B�s�A JOB SITE
APN 649-21"03
OWN+�ER�^,
CONTRACTOR DESIGNER / ENGINEER
,SPARil.?+
P.O. WX7 i•liG
9-291512A%CI-10I..AQUilv';'AM
.LA QU.(N'(A. CA 92253,
LA QUINiA CA 92253
(70()1771,4941 C.i311±t V96
i
USE OF PERMIT
ki.CNUI.i: FA0IL,Y DWELLING
!"I'3, .0 L:AW A3, LOT 291. PMMi`(' S. 0F,_5 l�+Gl.t�i�i BLOCK W.F�LI. Oft �
I;C)(�,E, .:P:LA•N t;fslSC:la FL'sb :f?I~'f�U�:CiL`► 7S'u f~C)iC �1t7i,'Tl!?Lis 1`1SU�PfC(i GL' ;
SAN4B k1_AN T1'x°E.
CL:iw ONI CONSTRUCTION d ION 11,71,13.00 S1,
('C�f2C:.�TlI'A'.i'9U �2.i3f) :alr
GAXACA C:Ai21'ORT ')30.00 SF
ES'M.A'1:E D COST O1, t ONS7-R•ti3MON
351,3M30
V t MM1'1' �'VOK SOMMARY
CONS'PF1UCMON KE 101-0100-418-(30(1
PT, AN (JMr.K, k F.S
110
1�1.Ct��"s1AVI CAL VEG 301='U�tV-�a!�Vu!} S136,50
ELFC WC-,Ai%:'E} h $14631
f'Lill�il'i3tldCll�1:.�-"��f�l�(�}-�'1,�-001).•. �t15.40
S'.(12,C7h3C3 :�tG9TlQ?d'.t 3"s ° - xtlyS 1Wli:"
GRADING ME 101.000-423-000
.INFRASTRUCTURE FFE 225-000.44M42 $6,uoo.00
A€d.'1' 1N PUBLIC PLACES r:S.CI: 70)-000-255•{300 $62-8.47
803-',l'OTAL MNS1'Et'iK."MN AND Di,.A.N C,:.HFC'K
LESS RRIE-PAID FEES
TOTAIL L'f H'1t1iTlI'FEFS DUB' NO
$9,1.02.05
1RECEIP
511V
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D E INAL
INSPECTOR
t
/IN• ' �.s
INSPECTION RECORD
F_ OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
'MECHANICAL APPROVALS
Set Backs
—� �`C
Underground Ducts
Forms & Footings
Ducts
Slab Grade
•— [ — LLQ
Return Air
Steel
Combustion Air
Roof Deck
_
— — li
Exhaust Fans
0. K. to Wrap
_
��� _ �G
F.A.U.
Framing
Compressor
Insulation
63� LC
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
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
A-7— 9-
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
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
t'
Final
,Z --
Utility Notice (Perm)
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