9809-216 (SFD)61
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 Facp. ate
ate"'.� .� Signature of Contractor-
OWNER -BUILDER DECLARATION
r
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.
( 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:
Cartier Policy No.
STt!11.3:Ff.FE D 1,371095
(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 subject1o,the
workers' compensation laws of California, and agree that if Ishould become
subject to the workers' compensation provisionis of Section,3700 of the Labor
41 /Code,I/sha`l forthwith comply with those provislons:
yDate: /£= Applicant—
Warning:
pplicant 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 Statedws relating to the building
construction, and hereby authorize -representatives of this City to enter upon
the above-mentioned property for inspection purposes4D,
tSignature (Owner/Agent) f ' ate"
BUILDING PERMIT PERMIT# CONTROL#
;cif}fI-2 � i►
DATE $29,.%.Qi�F LOT TRACT
8- 13
18
JOB SITE
ADDRESS 7.9-140 QkLLE BIRII
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.D.-OESi',1 T DE ;°E1.OPNI1°W j'
SPARKS CON 9fR.i.,rCT!O!"'
PA 60X 1-116
79-295 RAN640 .LA OPINTA. DR.
LA QUIN 1A CA 92253
LA. QLANTA CA 9.2253
f"j(5f)�7`11-)�d1 fi�;r3l,if 3.'��n
USE OF PERMIT
8 D. PLiUN k1Z 1.0T 21, PERI IT D00 NOT .iNCI'.UDi :3:.kji OCC Wi�LL OR
KJOL.PLAty i:Xi:E:K.FhE RHIWCFD 75SVI 0R N4ULTiP1,13, ISSUANCE O
8AME PL t4 TY`P&
CC1'STONICONS'bRUCTION 3,556.00 3F
POR.CI-YPA:1"'IO 446.00 SF
0ARA,Cd CA1U1OKr 6.36.00 8F
ESTIMATED COST OF 4:(DNS'i'.REJMt}N
295. 0.9.ss1
PERMIT FEE SilMS"RY
CONSTRUCTION FFR to).-Ooo-4.1??-000 31.325.50
PLAN C'"FC[:. FYX 101.-000-439-318
11 E ANICAC.1+'EE 101-000-421-000 $124.00
BLECTRICM, r, PC 101-000420-000 0 $122 1, to
1.01.-060-419-000 �2 3.Oto
1.3 RESID 104-000-241-000
Si13OPJ0 fb1 t'iC7N FF
C1R,U_ 711401 11ti 101-0.)-421-000 .)-421-000 $20.00
P-T—KASTRUCT URE FRE 225.000-44.3-342 :Kt)GG CA)
ART IN PUBLIC PLACES - REiSIC 701-000-255-000 $488052
SUB -TOTAL CONSTRUCTION AND PLAN C BECK
$8,71.0.m
LESS PRE-FAID ITES
V0.(tfl .
<� L
_
RECEIPTI r
DATE i�
BY '. t !
DAT F ALD
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Llit'
Underground Ducts
Forms & FootingsDucts
Slab Grade
i 9_
Return Air
Steel
_3
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
(-.
F.A.U. _-7 c7v
Framing
—
Compressor
Insulation
- / 0 -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate tines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
CGS
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
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
7'
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) !iy
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Rex:eptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
x
Final 1=
Utility Notice (Perm)