9804-175 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
04W Professionals Code, and my License is in full force and effect.
O :) ch License # Lic. Class Exp. Date
' CY M. ..
r W fi�3.1 8 f .12r1.1iO
(Y /te
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sl f "I � !
ZZ r- '�� / Signature of Contractor, w ° A •t�""%"
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J U m OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ dco 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). -
co () I am exempt under Section B&P.C. for this reason
LO
O N Date Signature of Owner.
rn
d< WORKER'S COMPENSATION DECLARATION
2 Z I hereby affirm under penalty of perjury one of the following declarations:
0 (.) 1 have and will maintain a certificate of consent to self insure for workers'
K LU compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is issued.
b Q U (X) I have and will maintain workers' compensation insurance, as required by
CJ Q Section 3700 of the Labor Code, for the performance of the work for which this
i 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ob O ST A.'i't, .f Mt 62,6355-97
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
Code, I shall fortt with comply with those provisions:
ate: Applicant i d t f/ awn Ny
,.v .., y; r u 1
Warning: ailure 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 & eachlpers66 affil
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 r
& 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. ; ?
3 y
Nature (Owner/Agent) i� f� l'` t+ tf :'` Date `" • ,,
12,
CON�TIROL#
• BUILDING PERMIT PERMIT9Xfjr�
4-1S
DATE VALUATION S �1)q� LOT TRACT s "3/0
41
JOB ADDRESS ` 4i./24 C'i�MO COURT
APN Qf��%:���i�i•�?.;
OWNER
CONTRACTOR / DESIGNER / ENGINEER
THE EXCHANGE GROUP'
ROGER, SNTlI EN13ERGER & ASSOC:.
78-615 NAPLCu DR
73415 NAPLES DIUVE
1.4 QUINA CA 92253
LA. t.,)UCNTA CA 92253
(7h0)7724)22-2 CBLO 18fT
USE OFy PERMIT
I
3FD LOT M. PLAN 48. PEALMIT DO-fi s NOT INCLUD-.E W..0 -Ch. WM,LS OR
P0,0L. l t.Ri`V C'H9,1 FFE REDUC`_ 13Y 75% FOR, MUL9'1PI R iS:��Nvt ks
OF SARifs' KL AN'1''� r,
TRACT ai,
1;01Zt;1.1iPA'Ff0 ' t MOO STS'
iFZR.J1OEICAti!'C:>R7 471.06 P
US T aYidV>iEJ) COST O.t+ CON SM1t1,10CI'1<CN
130, 154, 44)
N0,RN1411, VlY,''E S UMA MeARY
cot4nRuurtoN FDxt
IKAN CR C.'"K 027- !01-M041 -318
MCHATIRICtM 11i0t ti00 4n2_l-GUS)
ELis'(;:."►`.i?4f� AL Fill' S134.92
TILLt''MBING FIA: 101-000-41.9-0W) 5140.75
FY*803 141-}O241-0[0 $13.92
11,01 _00042i_000 $20.00
IId'i ftr1S�'R!7e a'URt E '' 2w ' 0004.3-349 �a 395,56
x.
Aft'k' f`N id"081AC PLACES -•1' ES1G 701-000-25.454M $75,39
ri.33':1 r, i:nNS"E',fS LCA i7CN AND1'L,nAi ?.'t'� C ±t
$�a.;Ma7, t;�
�' la ESS PREAPAL0 FEES
SO.UO
MAY 0.4 19918 -rO A& ER M -1-f FTE -14 011J,01NOW
�FY Q'(f L "e QId iii. N e^i t
RECEIPT
DATE .y
By
DATE FINALED
INSPECTOR
1e.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Waste Lines -5' - —
Forms & Footings
Water Piping
Slab Grade
Plumbing Top Out
Steel
Shower Pans
Roof Deck
- —
O.K to Wrap
Framing
'
Insulation
s
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
O — ?r
Drvwall - Int. Lath
GCtl —/•— .
K4 Y- ra I va.
BLOCKWALL APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts .
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Final
POOLS - SPAS
Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
COMMENTS:
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
Smoke Detectors
Temp. Use of Power
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines -5' - —
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
COMMENTS:
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
Smoke Detectors
Temp. Use of Power