0111-221 (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. ClassEp. Date
07/31t2oC
Date I Signature of Contractor
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.
( ) 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:�`�.')•;1, FUNS Policy No.`�,��$
(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 thatif I'rshould becurne
Subject to the'�workers' compensation -provisions of Section 37,00 of the Labor
Code, I shall'forthwith comply with thoshrovisions.
DateF�(( a�! r`r` ' 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, in1
addition to the cost of compensation, damages as provided for in Section 37061.
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building andSafety;
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 vohdif�
work is not commenced within 180 days from date of issuance of suc11h
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 informatin4js
correct. 1 agree to comply with all City, and State laws relating to the buil ing
construction, and hereby authorize je'p"Iesentatives of this City to enter u on
the above-mentioned property -for inspection purposes.
Signature (Owner/Agent)-• T �4 . —fk Date' "'t t'>•
/ BUILDING PERMIT PERMIT# 4
DATE VALUATION LOT 0111-221 TRACT
I
16 '04
JOB SITE
APN
ADDRESS 49-0.90 TIARCUO "MINTIR
649-1W4)07
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO BOX 11716
79-295 RMC110 L-A QUM'i`ADR,
LA QY ? TA. CA 932,53
LA, Cil': I14 TA CA 92253
(760ynx-1942 MR, :996
USE OF PERMIT
..+t
.0,4011Y, FAWLY
riF 0 1nT e_M PLAN WR. P.lr�'.}ZMIT DOES NOT 1�1k IXOP BLOCK Tide JAS,
CUSTOM C"DMIUC`i ION 4,243,00 SF/
27ORCak3l3aATIO 522.110 SF
710,00 V
ESIMAWD COAST C`9F COM,111U. C7.1.01H
35U"188130
4 ON031RUCITION FEE 101 -W041 -184)(M $9,5111$+.1
PLAN CHECK PEE 1 d1-000.4.19.118.3
I C1rAW3rUALFFF, 101-000-421-,000 Y3�:Siw
SLPCTRICt -C.L. FEZ 0I _0 :0-4.20-10(yJ 8246.71
i°L13MB6?dC3 FEE 101-000-419-000 00.41!-000 S203.8t18
S TRO 0113" MO3'1014 FEE - RESID 101-=-W-000 $35.14
OP14WHA, tR 101 C► : }2:3yf100 et0.fif!
1.)EVY3.,0PY-? LMPACTFEF;
A1+T ,nA P Jk1UC PLACES - R.WS11. 27"010-445000 "010.445000 S:3'? A7
8`15B -TOTAL =RMl:e•M ON AND PLAR C13FCK
$4,759 05
�9{
I
nuc o 6
'RECEIPT
DATE j,
� r
-BY
DATE FINALED
INSPECT
5
OPERATION I
DATE
INSPECTOR
OPERATION
DATE • `
INSPECTOR
!BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
Forms & Footings'(
/f=� - Z
Ducts
Slab Grade !;
_ -y
Return Air
Steel l i
2
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap I I
- z
F.A.U.
Framing (}
_ Z
Compressor
Insulation i 1
�j -/� Z,
Vents
Fireplace P.L. i (
Grills
Fireplace T.O. (,=
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath I(
Drywall - Int. Lath 1
Final
Final
- —�
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs 1 i
Electric Bond
Footings I {
Main Drain
Bond Beam ; {
Approval to Cover
1
Equipment Location
1
Underground Electric
} (
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i ;
_
Heater Final
Water Piping 1(
Plumbing Final
Plumbing Top Out ! !
Equipment Enclosure
Shower Pans I;
O.K. for Finish Plaster
Sewer Lateral I }
Pool Cover
Sewer Connection i "
_,�_
Encapsulation
Gas Piping
Gas Test
Appliances i
-
1:
Final
}'
COMMENTS:
s;
Final
Utility Notice
ELECTRICAL APPROVALS
Temp. Power Pole I `
Underground Conduct
Rough Wiring I f
- - Y
Low Voftage Wiring 1,
Fixtures ] 1
Main Service 11
'
Sub Panels
Exterior Receptacles I
G.F.I. ;
Smoke Detectors ] I
Temp. Use of Power, f
l�
ii
Final ; (
Utility Notice
(Perm) I i