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61
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
1 &3 1109
0.71
JDate Signature of Contractor
cr
t 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.
V) 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 carder & policy no. are:
Carder Policy No.
zkrrLT�I Ids. Co. s or f f$l
(This section nee no a completed if the permit valuation is or 10 . 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' compensativisionyof Section 3700 of the Labor
,ode
I y 1,v�ith compl X011 6se provisions.
ate/ , Applicant• _ —
r
Warning: Failure to secure Workers' Compens on. coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,. in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on"his
application.
:t
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to,. & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit.to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize epres ntatives of this City to enter upon
the above-mentioned property nspectio� puurrposes.
yrSignature (Owner/Agent. "�i+ 9`"- Date
BUILDING PERMIT PERMIT# CON/TFIOL#
DATE VALUATION LOT 9803-14)e TRACT }�
S901909.50
JOB SITE
ADDRESS
45-325 CAR OF LANE
rQ�-:1 S ilii
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CEN TRY CROWELL C;C3ibi".fNITIES
CENTURY CRO -WELL Ct3tMMUNCHES
Ia3S SCJ. "D" STRf3ET, STE. 42O0
1535 SO. -D" STREET, S'T' #200
SAN BER NARDINC) CA92408
SAN Big RNARDINO CA .92=103
;! 09)381-600^r t`.13L• 212f1
USE OF PERMIT
PIAN 3AR -STD - DEL RFY AT 1,A UUINTA NORTE
TRACT CONSCRUCT14N 1.445.00 SF
GARAORCARPORT 635.00 SF
ESTIMATED COST OF CONSTRUCTION
951, �atN�.SU
PERMIT FEE S11MAIARY
PLAN CHECK 17Q; 101-0(X)-439-31$ 1504.98
COINTfRUCTION FEE 101-000-418-000 - 5599,00
M}"sCHANICAL FEE 1101-000-421-000 $4770
1 L.EC_71 ICAL FTE 101-000-112x0170 $111.78
PLI.1AMINC FU- 101-000.419-000 $1.48.00
3TRONG MOTION FEE - RES[O 101-000-241-000 59.09
GRAD) NI G FEE 101-000-1123-000 $ti0,00
INFRAST121.tC"PUIt1 Nk:c 'x'25-000-44-1-342 42,1�t5.1Fr
n R,
SUB -TOTAL CONSTRUCTION AND PL O%N CHECK
$3,485.31
LESS PRE;-PAJ D I -T E,:
S O.N)
J L 2 1;.,3
TOTA . PERMIT FEES DUE NOW
$3,495.31
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
a SPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLDBNG
APPROVALS
MECHAN8CAL APPROVALS
Set Backs
0 C
Underground Ducts
Forms & Footings
_
(
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
O -Yj-
Exhaust Fans
O.K. to Wrap
— Q
F-A.U.
Framing
e —
Compressor
Insulation
_ Q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
o —
Drywall - Int. Lath
— —
Final
Final /
BLOCKWALL APPROVALS
POOLS -SPAS
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
—/1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/c, - —
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELEC7ROCAL 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
Find _
Utility Notice (Perm)
COMMENTS: