0303-123 (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
WProfessionals Code, and my License is in full force,and effect.
C 5 ch License # Lic. Clas Exp. Date
LLU 6409,34 E rI 61301%
~o Z r-- 'Date Signature of Contractor 'l
CO 0- r?
J U Q OWNER -BUILDER DECLARATION
LU Ljj I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law forthe 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).
cf)() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O�
O_ Z WORKER'S COMPENSATION DECLARATION
lt o a: I hereby affirm under penalty of perjury one of the following declarations:
H O () 1 have and will maintain a certificate of consent to selMnsure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q I 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
d rn I— permit is .issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier P1.ATIC-14JUi UNK%N K Policy No. 105,309
C Z)
(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 Cal fornia, and agree that if I should become
subject to the workers' compensatiom�rovisions-V Section 3700 of the Labor
3 Code, I sh�ajl�or�h 'ith comply with th sie prgvisior...-.•_..e.
X' Late: 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
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.
r:
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursLant 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 propgly,fgr insp 'tion purposes.
Signature (Owner/AWent) Date '_> a'
BUILDING PERMIT PERMIT
��
gC1i12
DATE VALUATION S135AAja LOT 164 TRACTJOB
SITE
ADDRESS �t %-419 CMLSEA C,:C)Fiii;l!'
APN 764-270-0.18
OWNER
CONTRACTOR / DESIGNER lEN INEER
1 '.A) A QUWA, L.sZ
31_WA 'i:-i0M 1:Z
60.313 TRZO Y PATCC 1AY
81.260 A TUTL 6 a
I.rA QUWA CSF+. _92253
BFRNfAL CA 92681-4
(909)833-8996 CBV, 6876
USE OF PERMIT
O" ILdC%I1!; F Adt-LY S)'WELLDIG
S e LUT 104, FLAN AUR. ( ..ALA 1. 4 1 . TIIATIU t9, 1. .
8,F) PER -MIT DOP8 H01T.IWCLLiDE BI_,CXX WAJAA'' POOL, SRA OR
17t't1TYWAY APPROACK
CUSTOM CONSTRUCTION 11330.0 of
PORCIVPATIO 4n.00 tis
rtiiiaR�•taiJC.L?R'I' ��6,f6f+ I:f�
E617 TED COST Off" Ct?.196rRVC'!T0N
rv,058.10
1�'.i'L''t': bHTYM a Sl•.T.k11.tIWel
CO NSIMUCT]OH FEE ) 01-C'00-418-000 $7bx.90
PLAN (:iF1P. X FEE 101-000-4.357-31€3 $632.1id .
MIEC•ILALAICAL FEE 101.000.421.000 586.30
MLEC TRICAL. F;lPLr 101-000-420-000 $97.45
P1.UNIRINO FIR 101.000-419.001] $11x100
3TIZONO MOTION FEE - RRSID 101-000-241-000 513.51
01111,I)I O FIE 101-ON-423.OPA 515100
DEVELOPER IMPACT PF'L $�,AbS•Ot�
SUB-TOTX, ( CONVMLTCWW AND PLAN CTJDCK
IM, x'f. FIAU) F ?V
$0.00
Ta-rAL, PEFOMY FEES :DUrl..NOW
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RECEIPT
DATE J
BY ?
D4:tNA6EO
INSP R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
4
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
10
Exhaust Fans
O.K to Wrap
p • C9 .5
F.A.U.
Framing
V-117,25 _e•3
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
7 . -
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Etectdc 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
SwAmr Lateral
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
Fbttures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use,of Power
Final
Utility Notice (Perm)
COMMENTS: