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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 Exp. Date
674074 i3 7� �` 7/311
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).
( ) 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.
(X) 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 STA
l7 { Policy No. 371(195
(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 Arkers' compensation' provisions of Section 3700 of the,Eaa l or
de, I shall forthwith comply with those provisions./
��.
Xte:42ii— , + h Applicant t .�6
Warning: Failure to secure Workers' Compensation overage 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.),agree to comply with all City,,and\State laws relating to the building
construction, and hereby authorize f'r`epreseniatives of this City to enter upon
Zature
above-mentioned property for inspection purposes %
(Owner/Agent) f ? Date
BUILDING PERMIT PERMIT9�8+19-20 CONTROA�L#
1
DATE VALUATION 051,3811 .10 LOT 1.5 TRACT ?Vv ® 1
ln�a -V
ADDRESS 79-080 CALLS 0.111SA JOB SITd
APN "9-21"U
OWNER
CONTRACTOf1Rt/ DESIGNER / ENGINEER
CONTRACTOR
, 1 y y+ �7 s rri `
T.D i.1G�5c"W' DE �t FL.0 ra�i E, N11'
SPARKS 4.l,.�NS ii.VMIM11
P.0.80X 1716
`9-%5i Re1,:NK;HO LA QMTA DR,
f.A QU1NTA CA 92253
LA. QUIN #'A CA 9275:
(700)771-1941 C"I.t1 2
USE OF PERMIT
SMILE PAWLY DWELLING
:fWL .PLAN CXECK FEL }UR)UC ED I -Wo FOR iVlCJI.`1'.I.PLE- !3.`AYANCH OF
SAdVE- . LAN 'rVPF.
CUSTr;4111 CO-NaTRUCT101111 4,213.00 S -
POftc,W)Nflo 522.00 8F
OARAGHUC;ARPORX 710.00 wF
ES.9tJ.I M t I) (=.i. 4.dk' CON.MRU 3 p.CIN
3511101 YMI.30
i'1rRNUT A ji' SUlatle ARV
CUNS`11WC 1'10N FEF 1.01-000-418-000
K,..ANC"IiEcXFFS 13
NIECRANICAL FEE 101.000-42:1-000 �136.5U
ETAC'1'11ICAL f M 101-000-420-0000
P3.. JA48TNG FM 101-000-419-000 $2V5.00
S07RONC NC3TION H -Ta . WSM 101 -000 -241 -OW X35.14
GRAJfNC} l MW 10.1-400-47-3-000 x"0.00
lffl,"S'C1"UC'XUREl~EE 225-0004431-342 $6.000.00
i1RT 1N PUBUC PLACES = RFS1r 701-iJ -25S-000 56:2.47
r
Suf1-T(—YfA1., (.!ONg'fftUC'I ION AN1,)PI. AN C1{1iCK
%),1o2,05
ESS PRE -MUD FEES
$0.00
RECEIPT�y
DATE
BY / f )
r
DAT FI
INSPECTOR
INSPECTION RECORD
OPERATION
• DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap
L Gj
F.A.U.
Framing
-Zp_ G
Compressor
Insulation
Z = q—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
BLOCKWALL APPROVALS
POOLS - SPAS
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
Sewer Connection
rel
Pool Cover
Encapsulation
Gas Piping
Gas Test
— z z- 2/ �+
Appliances
Final
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
c
Final !Z,/
tftilriy Notice (Perm) -
COMMENTS: II
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