9706-125 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
CV LU Professionals Code, and my License is in full force and effect.
p Z) M License # Lic. Class Exp. Date
O 6740/4 ti 7l31e5�7 ,
Date
Z Yf / r// 9 Signature of Contractor f
J /
P: r OWNER -BUILDER DECLARATION i
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
J
~ 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 B&P.C. for this reason
N Date Signature of Owner
ON
Q
Z WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations;
Lo H 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
.Oro J Q performance of the work for which this permit is issued.
Q C) ( 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No.
N O "3TA7EkIND 13`�4CI�S�tG
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
subject to the workers' compensation provisions of Section 3700 of the Labor
fode, I shall fort with comply with those provisions..�J ;
ate: ��pplicant — •L* / 4 l n� is a �r`e i�
Warning: Failure to secure Workers Compensation coverages 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. . . y_
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 i-
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
c •/nstruction, and hereby authorize representatives of this City to enter upon
e above-mentioned property for inspection p�:,o;es,,,Signature (Owner/Agert) —� A *Y` �h �Date
t/
} a
4
BUILDINGPERMIT PERMIT# CONTROL#
9706-11125 5399
DATE -y VALUATION �1�t1.0�LOT TRACT
II 1 .d10 l3 2ti3<i
1
JOB SITE
APN
ADDRESS 78-592 ICAH ILW WAY
6d�r (ix(1»UiIS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'11) 0 EsriWr DIE E1,01"MENr1' LY
SPARKS CCihSI �2: tG'tltlPd
!'iJ k�l,)X 171.6
79295 RANCHO LA QUIN)'A. DR.
LA.Q)1J1'N('A CA 92-1$3
LAQVINT.A CA 82253
(760)7'71.1941 (;:113 (,# 2996
USE OF PERMIT
Sp, J)
LO i .i.5 ' '.i t1RAZA Pt,jkN 2, PLAN CHECK i+UN REDUCED BY 75%,
I%OR M111131i' A ISS141, 01 SAME KAN'lYPE,
FIS"I'R �C NON 2, ulS. :�
110RCHWA1110 .1:15.013 SF
0ARAQVIC„ AltP MV SgS,4sU Sr
ESTIMATED COSTOF CONSit'ft[1MON
1",409.00
0.'!!:tttllfl'(' i�tt:.l; lil).iillY(A1t1.'
PLAN CkiiS(: f6 FW, 101-M)4.49-319
CONE 3']."4tIKl fION '�i .3 101-000-41"00 S'?580)
P:fFCHANICA1 FEE 101.014-4.21.000 $11 i.`61
E ( A _-0 RIeAL FE V 01 -MO -420-000 5171.03
f;'LLIMl INQ HE' 101-O() 419-4)00 S10.00,
S` ONQ M0'! IQ?41,T-1$l;:1li? 101-00-0-241-M) $19.04
GRA4)ING FEE 101 -000 -423 -OW $20.00
INF4t.ASTRuC'1'008 f -R.' 22,5-000 443-342 M.` 4939
ART w l?1. BLICt�1 At,`IiS -103810 701-000.255-000 S�3l.f►6
PLAN r;Fl4Y;'f<,'M71 101-000-43-9-318
r' B-TMAG C(3NST`KU(;'I'hON AND KAN CHECK
LESS. 'PRE -PAID .FEES
egg
4596,7:2 :,•..
..
'1170. At, P.(:4tMI'.i sb 110"5 Ot1.T: NOW .
S6,1 14.33
RECEIPT
DATE
BY
DAT FINAL
INSPECTOR
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 -
Exhaust Fans
OX to Wrap r
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
-Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 4L �WU7
Drywall - Int. Lath
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 I
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 — /
Appliances
Final
COMMENTS:
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)