9809-215 (SFD)Cl)
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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 aD to
i 674074 B
,-at-/r!1-''"h' Signature of Contracto ^" j
' ! J
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 & Professio6als
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.
(y) 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.
STATE FWD 137 1.tY.t5'
(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 p�isions of Section 3700 of the Labor
Code, ` shall forthwith comply with t ose pr �� ns
Date: -_074 /44 Applicant i x
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 representatives of this City to enter upon
the�a_b6ve-mentioned property/for inspection purposes;��_•,
✓Signature (Owner/Agent) ate
BUILDING PERMIT PERM' 9840..215
CONTROL#
py
DATE VALUATION Si6%91..7.'Z0 LOT 20 TRACT .)90.306 O `
JOB ADDRESS 7�-1301,°c�.�aLE ffid &
APN /a�y+_216-0a
V�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�i'.i J. D17SER i..6EV.fwf.rO M -ENT
Si'l/.. IUS isON'SRlRUICdii.fN
P.O. BOX 1716
779-295 I—ANCHO LA QUIN.iA. DIC.
LA QUINTA f.'A 92253
LAC?( IUM CA 92L3
(760)77I_1941 011A 2996
USE OF PERMIT
MOLE 1:FiMILV DWELLING
SF13, P Atrr'IL11, .LOT 20, KRtl4A ,DOES NOT iNCLUDE BLOCK WALL C%'R '
1:10OL,£'LAN CKEXX HT -K01 .:CO) 7513K FOR MUl':'.i'iF'LE I SSUANC% OF
iAMI's .PLAN TYPE,
i"UiTQA,1 i QNSTR C ION 3,076.00
PORCHIPATfU 580.00 Sty
GAXAQH/CARPO.RT 691W .3
ETSTIAM1'ED COST OF CGN 9'E RA 'JON
769,11`1740
PERIMIT FEE SIlii'iMAR Y
CONSTRUI 1t'1ON FF.E 101-(301}-418-000 S.f.2V3 00
PLAN CH.FCK FFE 10,1-tMO-��t�-3�.`� SZ17,07
,M1s ITANICAL V111 101 -0 -42.1 -QUO 5124.00
MIF.C:71tTC AL rUp lii.i-t71)1)-420-000 $205.52
PLUMBING 14T, 1131.000-419.000 $183.00
R -FSM 10t -ON -241-0M
GR.ADING VEL' 10.1-000-47-3-000 520,00
fNFRAS'11tUC;TLTREFBI, 225-000,443-342 0.697.0:'
AWC tN PUBLIC i`'.1..ACF.3 - RESW 701-000-255-,000 5402.29
C11i3iIUALCONS11tUC710NAND PLAN CHECK
€.1sSS PRI?.PALD FEES
M00
TOTAL PERMIT 1kELFN'L UP, NOW
�9���1itt:fl4
RECEIPT r..
DATE , l
BY��,�y�•r/ 1r
DI F111ALE
INSPECTORJ
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
_
/lG
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
— j =
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
J
Drywall - Int. Lath
L/
Final
Final
BLOCKWALL APPROVALS
L
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
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
--7 — qc1l S
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL
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
c
Final
.Utility Notice (Perm)
— !�
APPROVALS
COMMENTS: