9807-266 (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
N W Professionals Code, and my License is in full force and effect.
�. 06 License # Lic. Class Exp. Date
� W � ,>•I��l�?t ti l.lJiJjJy:1
f`
Z r— ate �ZSignature of Contractor '
tp0�
JI. -
OWNER -BUILDER DECLARATIO
LU WW ^ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
C'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)a Q WORKER'S COMPENSATION DECLARATION
Z
Q I hereby affirm under penalty of perjury one of the following declarations:
HO () 1 have and will maintain a certificate of consent to self -insure -for workers'
K W u- compensation, as provided for by Section 3700 of the Labor Code, for the
nJ Q performance of the work forwhich this permit is issued.
QU I have and will maintain workers' compensation insurance, as required by
j U Q Secti(}() on 3700 of the Labor Code, for the performance of the work for which this
L' LO permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
ao C,ULDEN laAGLE 1114N. NW(1 `IW4406$-rel
g (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
su ct to the workers' compensation provisions of Section 3700 of the Labor
de,,sha 19r1hP**,comply witl tijos ovisions!
1/6q6
ate: Applicant
Warning: Failure to secure Workers' Compen ation 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
a of the Labor Code, interest and attorney's fees.
rt•
IMPORTANT Applicationis 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 Ouinta, 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'
co s'truction, and hereby authorize representatives of this City to enter upon <
Zt above-mentioned property for inspection purposes.
ignature (Owner/Agent Datej�.�
BUILDINGPERMIT PERMIT# CONTROL#
DATE / VALUATION $116,767.40 LOT TRACT -7 3 8
JOB SI
ADDRESS p5445 S�K i L :
�APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
c:.,NTI. TY OR(MELI,0Ul:1N4t1N2T1E
153.3% ISO, ".u" STREET. i, SST'. 0200 -
1535 So. "L)" S'1'RL'• ET, STE. 9200
SAN1 HF.tiNAliiilNt7 �_A. 9.:d(?S
Sf�tV�OLR.i'3e�t,r�1t�C'a CA9-2408
1
(")N�I-6Clill CIBI tr "'120
USE OF PERMIT
SINGLUAIMILY DWELLING
£:iii). PLAN JCRO, LOT 7 PER&UT 1.-1 X5 NtOT INCLUDE, Lir.00K 1:irtAL..LS
POOL..
` R'ev P CONSTRUCTION 2,010,00 SF
GARAGE1 CARKWT 389.00 ASF
ENTIMA` TO COST Ot' CO,^.STRUC";rIONT
116,767.40
PER;NUT;i�" OW SUii4IV1ARY
t'tiitiSTILtX:'I'KANTI�:L 10I -arm -4184)0 8699.00
111 -AN (`f�1 C-9 Fff` 1.01-0011-4A9-'419 5586.0
IVIEC1IAI dlCAL 1•+7 ti 101 -ow .X17.60
rt L'C."I'RIC'AI..t LI: 101-X1(,0•-420-000 $126.63
PL IANAk3ING FEE 1014)00-419-000 $172,0o
�+`l`1iC1 1t"r A•(<?TLC'!?�7 FIT - W 1 ff? 101.000-7.41-000
;7"Ri%S)1TrG FEE,' 101-000.423-000 Rzn.tr)
I1vJ�'RASTEtC1a: 11REhLL 225 -000 -44A -3d¢
AK'1' IN PUBLIC PLACJ- S - RESIL: 70.1 -01[0255 -OWI
j' � ;;# l'. (Y1T�rZL t:ONS1R. 1E'l 1UN A_Nll ft,w 11714ECK,
$1,'311.69
r. LESS PR[ -1'iVD f'[i):S
` ^ 'FiD'iAI, >i'tL=lEt1NIFF 1��?;1N S li�iih; NOW.54,3371.69
A,
RECEIPT
DATE
BY
DAiS F D
INSPECTOR
u SVS
'INSPE=CCTIGN RE�OO Ra
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDNG APPROVALS
Rfli ECHAN AL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade — i ,dS
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing a-3(41
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulatlon
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
FinalPOOLS
SL®C Krftll.BalL.L APPROV S
- SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMUNG 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
Sewer Lateral
Pool Cover
Sewer Connection _
Encapsulation
Gas Piping
Gas Test A
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Love Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Srrj�te Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 5-7