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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
i
/D- 71 � 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.
(K) 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:
Carrier Policy No.
(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 vyorkers' compensation/provisions, of Section 3700 of the Labor
Gode, � II forthwith comply witpi'tWose provisions/ -
Date: �� , Applicant ,i%!,/1.. _f, - fl, )
}
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. It
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)` {«�"' ` Date.
-
BUILDING PERMIT PERMIT# � CONTROL#
4)844-171
DATE VALUATION ��.�t� t ��.�t LOT �,� TRACT 27T,
{
611,14? 7 6'9 7
JOB SITE `
ADDRESS 7"44 CCDMO COURT
APN
609-030-00
OWNER
CONTRACTOR / DESIGNER / ENGINEER
tIi Cf1 A :!t;tr
ROC; 17...SNC11.t N111t.2t",3 it&ASSfYC,
79-61 + NAPLES DR
781;1 y NAPLES DRIVE
LAQUINj'A CA 42253
LA, QIJ1N`I'A CA 92253
f`7c�fi1'772.02"2 C:Ri;,t 1R5R
USE OF PERMIT
61, L, L(st i1, 11, A14 4.,1%(. PL -AMI 1',000S NOT t1+it'L00)4- `kil..{JCK Wi%,LLS
OR VOOL, t':t.AN (;HEXX FHF R1FA)Q0.3) BY 15111b FOR Mt)LTJP.U'
13SL1ANCE OF SAW-. PT AN'rYPV.
NZAC" r CONS;!RUCTIOW 2.200.00 F
10.00 SF
i}A7tt1i};f;Aft.f>C)FC')` 471.tk) 4h
4111
N%TIA1ATR :iy C_'i; 9f OF CONSTRUCf ION
130,154.6ft
N�;ielviiT sai�in.��A���
r��a'(�:
}�9 �/� �1 y� [, V48.00 ep �^,r�
C10N.TfFWft"f'T.P, N FEJT 10t-000, 18-000 $'!48.510
Pf1A'NC1tPCt4 F`F1i 1gt-r}f)0-.3a.31'i •, $154,69
fECHA141CAL FEE i f? t-OOtt-�? 1-U(3t3 4bt)AO
1:3.1JCTRWAL Fi3s 1,01-000420-000 $ IM. 9-1
PL4-T?MfNG FEE ?: 101.-100-419-000 3140.75
5'►'�<3:Nc�h�n°7rTC)?si'.'E'�:"F".-tafiSST) � 1�)I-(tlNl :<�Y-0S)C) �13.t)�
OWUANG I,"f; 101-000-�12.�-000 $?t►.Otl
fNFRAS"IRUCT(IRE F111, :2ti-000-Rt4w-341? $1,895.56
ART rN P1IBLlt.; PLAC:E.S - RE51; 70I -OW -255-000 S75.39
t
C
,f r'A14 Ct? iS"(}Zl i(YI1C31�f ANt t pi:,t�iI C.Fa3?f.",�;
$4,242-13
LESS PRETAID FEES
$0.00
MAY o 4199a
E ,CC6r1°'r�
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
.Y -f -
Return Air
Steel
f7.,
Combustion Air
Roof Deck
— -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing- fs�j
I -
Compressor
Insulation•
'�2 (-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines. .
Party Wall Firewall
_
Exterior Lath
Drywall - Int. Lath
Final
Final
!— —
POOLS - SPAS
BLOCK
11 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 APPROVALS
Gas Test
Electric Final
Waste Lines
j_=4 _
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
Pool Cover
Sewer Connection
- - j>!
Encapsulation
Gas Piping
Gas Test
Appliances
/(_s
r
Final
COMMENTS:
Final
Utility Notice (Gas) Fj}/ U
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
t
Final
_
Utility Notice (Perm)