0303-122 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O :D CO 'License # Lic. Class C Exp. Date
r' 0 LOLLI
,6:40
r— Z . D'ate � Signature of Contr ctor
OOH ,11 9
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C)/ OWNER -BUILDER DECLARATION
W W r1_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
ce)() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
Oa)
Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () (�` I have and will maintain workers' compensation insurance, as required by
O C) Q Sect oh 3700 of the Labor Code, for the performance of the work for which this
d Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 19ATN,XNAL UNION F: Policy No. " DO15309
obs
r` C7
J (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
3 subject to the workers' compensation,provision�s'of Section 3700 of the Labor
Code, 1•shall-forthwith comply with those,provisions.
,Drate: � t 41 t,- 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
111110 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. I X.-
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursJarit 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. fl
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 i
• correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo�
the above-mentioned property,for inspectier purposes.
Signature (Own rr/e _Agent) ~ Dater
BUILDINGPERMIT PERMITO#,V1 ?2 '
DATE VALUATION $117,691.10 LOT 126 TRACT 300 +
JOB SITE
ADDRESS X81-747 bn1`rLEBIS_Ucf( LAN
APN 7&41-Vf4 -018
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SBL ALA QiJIWA,1=
M11-1EA HOMES
60.311 TlRTtX)GY PAttICWAr
81.260 .AVWTO:C 62
LAQUOrIA CA 92253
THERMAL, CA 9.2883
'(909)833.8396 CBL40 6V6
—
USE OF PERMIT. - -
8rN OIX uA2�lIfi.Y iSdiIF1?T E.�Y+i�3
S b a 1.Vt A, Ad, Puuq -for's. ,. .1W14l l:. !rd Iv 1.d i4 ♦.l.ru ��Y'+a2Ln.i+i',
1 AT,Li� POOL4 811A OR DFUVEWAY,AP?ROACH
CUSTOM CONSTRUCTION 11359.00 3F
PORC.H31!?A'1IO 714.00 SP
i3AJ1A,0FJWP0RT 474,00 SF
ISI`.➢I!! ATED COST CSP OCkNFI'RUC.'.7'10N
11.7,691,10
P RRVOri FXE .W&IM AJ" Y
CONSTRUCTION J179 101.000.4119.000 $707.50
PLAN CHWX FEE 901-000-43i)-818 ;$572.93
MECHANICAL FEE 109.000,429.000 $'J5.00
ELECTRICAL PER 101-000-420-000 $90,41
PLUMBINO FRE, 101.000.419!,000 $116.'
STR.OIdf.1 MOTION FLrE - RE -SID 101-000-241-000 $11.77
OR.t.D NG FEEK 101.000.42.9.000 s[S.00
!D!IVE).,C1P R.IMPA.CT FEE $.2,405.06
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SM-�'l'J fAC ! ;Uid.513� z:T; l C)1 .A�2'1� .F'I.A1�9' G"I:
$3,989.26
IM.AL 'FFR1%W FUS NOW
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KNAN'CF ri.na, •, j
RECEIPT DATE
BY BY
D FI L
I TOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
zw,
Ducts
Slab Grade
Return Air
'
Steel
Combustion Air
Roof Deck
/
Exhaust Fans
O.K. to Wrap
o•a 3.:
F.A.U.
Framing 77
— yr
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
_
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping A
PLUMBING A PROVALS
Gas Test
Electric Final
Waste Lines
3.f
Heater Final
Water Piping
1,Plumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer'
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
Utility Notice (Perm)
COMMENTS: