0006-243 (SFD)LICENSED CONTRACTOR DECLARATION
• U) — 1 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
. ,. N. Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
CYU-)W 690645 B MC A 0t5,r3gd2C
IZ IY .Dry i. !
Z r --Date en '/ Signature of Contractor -x
O
O C) OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ EL 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0() I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
p N
0)CL Q WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
m0 J Q performance of the work for which this permit is issued.
Q () ( y` I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
LZ permit is issued. My workers' compensation insurance carrier & policy no. are:
Cb Carrier 1199, COMPANY OFT Policy No. WDF17ON1900
0
Q (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. ��
Date: Applicant }'� !; l!• �!�.,.
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.
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),"" f � • s t'Date, %
3. 7 -dJ BUILDING PERMIT PERMIT#
DATE VALUATION LOT ONLY- .3 TRACT
WS,044M 7 25389.4
JOB SITE
ADDRESS .mit}_% c� ss }?02ta 1?RTm
APN
769 -050 -OM
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RXr UgVFZ iyt, 24T4.L, INC.
RJT INWS'IIttENTS, WC,
14251' VN1VM=rY DR1`4E
1425 E WMMUT1Y DRIVE
PROEM AZ 83034
P1110E OLTX AZ 85034
(602)257.1656 C=I'a..9 , 4.990
USE OF PERMIT
SPD LOT 7 PLAN 4A PERMIT DOES NOT MCLUDE RLOCK'ir>IALLS OR
POOL, 75 % PLA14 CHECK FEE 11FIDUCTION FOR ISSUANCE OF NAME
PL&N Type
CUSTOM CONSTRUCTION 1,984.00 9R
POR.CI•IIPATIO 7;.00 SF'
0ARAOF1GACrPORT (011) 9.466.80
M COST OF COMSTUD ON
1fi�"s,O44M
y �py�y �Y gyp�g � •�?t'�Sy'1.'.[zt+.F.�1
F E.f6.1•yM r F' n s V.L1iA,dY1Jtl YC ]6
.
CONSTRUCTION #SLE 101-000.418.000 S 70.50
PLAN CHECK FEE 101-000-439-318 $177.10
MECHANICAL "M 101.000,421.000 $60,00
L?L9CTR1C.A1, FEE 101.000-420-000 $1.76.60
,
PLUhfB rN0 FBE 101.000.419-000 $157.00
STRsiNO MOTION I'EE • RESID 101-000.241-000 $1C"
`
ORADINO FEL 101.000.423.0045
D V OLOPLR IMPACT PER.
(7)
jaw {�
SUB TOTAL COMMUC'X1014 AND CHECK
$3,343.30
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RECEIPT
DATE
BYf
DATE FINALED
INSPECTOR
�f/�7771
1p ��
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
O.K to Wrap
-
F.A.U.
Framing
,3• Cliff
Compressor
Insulation
�� C�
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
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 APPROVALS
Gas Test
Electric Final
Waste Lines
L� d
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
J
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)��