9809-217 (SFD)U)
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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
6741074/ 8 _18
r
pate />1f Signature of Contractor, s
v OWNER -BUILDER DE LA ATION
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.
( ) 1 -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, fi'UND !.37'1(05
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that,if-fr hould become
sleet to the workers' compensation •provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.`
/ate:/i'? a [%fr`$'b Applicant f!. • ""`'4 t
Warning: Failure to secure Workers' Compensations overage is unlawful a1vid
shall subject an employer to criminal penalties and civil fines up to $100,000! in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the iGe-mentioned property) r inspection purposes.
Sle
ignature (Owner/Agent) '" > Date rr
BUILDING PERMIT PERMI9X09-217 ' CONTROA�LN
DATE VALUATION SIS -1,3811S.34} LOT 22 TRACT c�81 0 8
JOESSIIEFlU �yCa �a sr
ADDRESS , 73-.1.35 CALLE USA
t. ��tV
APN �$:�„Ll�rliti3
OWNER
CONTRACTOR / DESIGNER
r�t�fii 1� t1 1
I.N..
�/ENGINEER ^r!.t
,tai”.�`�.R,1K..�l.0N,';;71,Z_IJCi.0N,
P.0, BOX 016 16
79-295 RANCHO LA. EaLJIN ADR.
LA QU19rA CA 922_53
LA QUINITA CA 92253
?t5�)771.-1��41 C.'¢i ,it 2996
USE OF PERMIT
S.INC3Ll. RA.MEL'I' DWELLNG
SHO'. PLAN W. LOT 2J, 1%EI' MT.T D"I S NOT BLO K. WALL Oft
POOL.PLAtd CKKIK FF i RFJ)U4iH=F.} 751% FOR MULTIPLE 138VAt` CJi OF a
S ANIS PLM TrPfi.
uU.33TOM CONSTRUCTION 4.24100 Sc -
I OR0,`WPAT 0 522.00 SF
G1AKACIFYCA:RPORT 710.00 SF
s STIAM,TET) COST OF CONSTRUCTION'
3S1,i33.30
PERNOT FRE, SUMMARY
r: 0N,'.n*Al, Crf0?4 FEE lot-t?CRl-418-000
PLAN Ci 70Ki , - � 01 (►OCf-t! ��A 31 R � � Oi1,� i
XIIECIWOCAL.F&F. 101 •(,110-42,1-000
ILU1111'I1TCAL FR6 10.1-00OL420-000 :2,46.51
PLtrtvtldRNGFFE 101-M-419-000 32f9a �11J
STl?OiJCdMr)TlONI FnE- 11,08tf) 1.9 7 44 o01)
(MADlNG KE 101-000.423-000
INF1tA37RUC'i°f:IRL, FEE 225-000-4413 342 $11 och).00
Aft'1.• IN PUBLIC PLACES - HES13, 701-000-255.000 r�i2it.4'T
SUg-IMAL C0N,ZTR1X1!0N AND P1.1 T CHECK
$9,107.05
LLS.P'P'M-P -1ti) FEES
$01t?'')
TCi'iCAL Jk'.l }1.R9ib"l FEES DUENOW
RECEIPT \
DATE !
BY f eyf �,�g.)
DATE F ALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs - —
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap G -2
Framing — _
F.A.U.
Compressor
Insulation -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
_ GUI 0galc
Final - - oPOOLS-SPAS
BLOCKWALL APPROVALS
steel
_
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines a4f
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
Final` GO _
Utility Notice (Gas) CAJ
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
N ility Notice (Perm) Z�—
COMMENTS: