0303-110 (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 # Lic. Class Exp. Date
6405134 1't 6130103
Date -4i46�� Signature of Contrac''torL
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 & 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.
(IV). 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:
Carver NATiO)iAL UNION F: Policy No. 703"09
(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 provisions of Section 3700 of the Labor
Code, I-shral f tthwith comply withUtho"se provisions„p,_,.
f�te: ICD: a
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 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 above-mentioned properryfor inspection purposes.
-Si6nature (Owner/Agent) Date
s,
BUILDING PERMIT PERMIT�#��3i0
���
DATE CAL ION LOT 1 Vii TRACTJOB
SITE
ADDRESS 81-687 mma"aM1US`E LA.firl
APN '764-270-018
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WM&LAQLrINTA,UZ
RWAHOWS
60-311 Tfiil:.(7CrY PA VTA'Y
81-260 AVENUld 62
L& Q11. °A CA 9225:3
'fIMMAL. CA g28&3
(903)833.8996 CRL4 606
USE OF PERMIT
Lf. Pa M L Yr"WA ji
a''YJ - i 1 IA1a 2'i.Hlli "Jd iUL.' T,6lai' ^n K YPl i..
DON, NOT INCLUDE BLOCK WALU3, P001.,OVA. OR DRIVWA'ST APP.'RO.AC H
CUSTOM CCi?.+ta TRUCfION $I33.0t18F
PCkllf. HIPATIO �11109 SF
GA13AC)WAPPORT 510,00 3F
ESnINANTED COW C;FC:'ON'1M'l1MION
XW1303.60
lfi'KCtW..1u"AX gubn&Wy
CONUTRUC'TIO)l FEEZ 101.000.4,18-000 $9331!0
PI.&N CHECK "M 101-00-4.'39-318 'V751.79
MECRKINCAL FEE 101.000-421.000 ..11M.00
XLW,TRJCAL FFA _ _ 101.-004-420-000 $120.34 ,
PLUMPING FEE 101-000-419.OM $142.00
STl;f�NO MOTION PEE - HESM 101-000-241-000 $1a.33
OR.ADINO ME 101-060-423.000 SK00
OLT L1,DPZR IMPAt.7' PEE.. $405 00 :
FUE DEPOSIT 101«000.439.318-�50,0t1
{ RMWrAl'- t�0�:3'&MUC BOAT AM FLAN C")TIZI .,l<:
w.._...�z= . , .. .xJR33 PES, -PAM) x= 11,
4750.00
14 A
FiN"IC"' U21
RECEIPT
DATE (
�'
BY - ` V '
L �-
DAT INA
INSP R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
1ACombustion
Air.
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation ,J GUM.Lj
D 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
D 3
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas, Piping
Gas Test
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
Final v VA
Utility Notice (Perm) - % - ,3
COMMENTS: