0110-065 (SFD)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
Jr -
1, W03
�J
Date { Signature of Contra/'ctor•.
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).
( ) 1, 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. DECLARAI{ON
I hereby affirm under penalty of perjury one of the following declarations:
(f) 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.
( ) 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 9TATE FUND Policy No. W-0.0001736
(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 Califprnia, land agrees that if I should become
subject to the workers' compensatioh provisions of Section 3700 of the Labor
Code, I sh ll forthWth comply with ifilose provislons.,1 �t
Date:J?).4-Q ' Applicant Y ).i
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on , his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
,permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize�,representatives of this City to enter upon
the above-mentioned property for inspe ctio %,purposes
_
Signature (Owner/Agent) <� �`k ^>-ia Bate
BUILDING PERMIT PERMIT# ;
(11
DATE VALUATION LOT TRACT
JOB SITE Wr
ADDRESS 4944, RANCHOLA.1 RCWD
APN
&8_1015
OWNER °
CONTRACTOR / DESIGNER / ENGINEER
TRAMSI V EI`1 RGUSNO W
51968 10133.7A"S"TAMe 102
78,401 F t(a'EMAY 131
IBM 17)TM CA, -92131 '
LA QT:+'INA CA 9225.3
1`'!60)171-33133 CrEI 4 4912
USE OF PERMIT
4117T. WLY
S:F0 , £.CIT 151 PLAN AN 3D. PPRMI T' DORS'NOT 1NC,1..t.tDE BLOCK `WAE 14% r
P001P813A OR.C'fWYEWAY.th3'PROII.CU. 15%P '4t:Hl`�4rK: FZ REDUCTION
PE
PON, TSDUANCE OF MU1~,TWX, , OLAk1 TYPE
i
TRACT CraWSTRUCTICYN 3,."x,00 ,IF
Sj��ydr.A011sy
� P"Ab`.f,L �A3319,.i 4liL A VOA,9i S
'
2.71MATKI) COST OF CONSIMOMOR
213,672-M
dl:, Y
P,�1ry"YErN SUMMARY w
Tl•$'}:
•bI4,6�1'FiUCTY.0-m
4t'tk 64m "m 1C3t-('. t2 -d3 31S .. p14.fv
Mc.:X ANICAL,FRE, X01.000.421.000 $92.$0
l%Zr,TPJr_A L VFV.' 101-000-420-000 $171,17
PLU1dlUta0M9 $ 0f,.25
STr'�.ONO MCa'1'ION PU - RES113 04-00-241-000 $71.37
res? A tJ{1�� �, 1 � dOt96•�•`� � ut3gt� �,@Q
J3,TVX1,0K?A i:dlPAC`P FEE �1,?iF;�i f30
2' 0.0..00.445.OW WIN
x:13-'TtYY1'AL '% s3MUCIT1;011,414DPLAtd•C.F'.3
y $3�E3J.t�l
cr,"I OF L.'1I J 1 A LESS k"Rr&-PATD:1P.W_3
RECEIPT
DATE
BY
AT
DFINALED
- 21— 9.
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
'(._
Ducts
Slab Grade
Return Air
J
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
—L5�_�j
_� �/L_ %G
F.A.U.
Compressor
rd _
Insulation
Vents
Fireplace P.L.
/.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
7_/Z_ 6Z j�
Final�
�C�
—
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines `j /�
/ Z, Z s
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
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)
— —