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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
728102 B Mc 9,130,1N
Date AN' �!' Signature of Contractor
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.
(,e) I have and will maintain workers' compensation insurance, as required by
Sebtion 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. OLD Rx:T°UDLIC INSU Policy No. MW(NODA5400
(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 shall forthwith comply wito;thos provisions.
Date: 200 • 14' 4 A Applicant ��
Warning: Failur6 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 (3'ode, 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 property for inspection purposes.
Signature (Owner/Agent) �,)Il le Date AJ /11
BUILDING PERMIT- - PERMIT#
DATE VALUATION D14S,=Z.20 LOT 138 TRACT 29323
JOB SITE
ADDRESS 79-.930 C01ME MEst'iet 0
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LDWARkIaME.3 O1' C'l4L`-h'C!IdCA.
LIMNAR HOMES OF C.'ALTzORM.A
78-401 C 1:111£ !J'1AY• I 11
78-403 C EUGHWAY I I I
I,AQYXITC.A CA 922S3
I:A QpDPCA. CA 92253
(760)777.0131 Q13WN 3434
USE OF PERMIT
WN C3''.i.E 17AMU.Y DWEL . ITCH
SFD . LOT T33 PLAN 4YA. KRMIT TOES NOT INCLUDE. BLOCK
WALLS, P004 PA OR DRIVft WA`Y APPfZ0ACT4
TRACT C ONVITRUCTIOld x, 11.00 V
PORt:HIPATIO 53.00 STf
a- ARAC;L?lAMOPLT 423.00 3F
t ,
VST MATED COST OF CrIORSTRUC:1ION
10,382.210
FEMUEM. SUMMARY
CON11TRUCI'IM3 I'`I3E 103.000-419-000 $900,50
PLAN CHECK FEE: 101-000-439-318 $6591.39
MECHANICAL PEI.. 101-1000-421.000 $53.50
ELECTRIC= MR 101-000-420-&03 $129.89
PTI AIkiTHO PP -19 101 -000-4119-000 SAA.75
STR.OWEI MOTION FSE • RF:SlO 101-00U-241-000 $14.59
C1P. eT D10 PRT%, 101-000.423-000 SUM
izT;11d'EI.D.P21 IMPA.0'T F99 I;L,40i.OG
3IM-MMAL CMISH20011 N AND PLAR 0-MCK
LESS PRE -PAM 1,2F.9
$0.00
V
RECEIPT
DATE
BYFl
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I SPECT
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11//J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
_ _
_ _
_ _ _
Underground Ducts
Ducts
Return Air
_
Steel
Combustion Air
Roof Deck
O.K. to Wrap
_
_ _
�_� _
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
_i� _ _
Vents
Fireplace P.L.
_
Grills
NSZ/
Fireplace T.O.
Fans & Controls
00
Party Wall Insulation
Condensate Lines
wo
Party Wall Firewall
Exterior Lath
_
/
Drywall -Int. Lath
Final
Final
_
> _ _ ut W4
POO S - 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 APPROVAI i
Gas Test
Waste Lines
�
� _
Electric Final
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)
0C Ot
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
y
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
_
Final
Utility Notice (Perm)
_