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0011-205 (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 i3 `, '/ / �' ..10/31/2i Date %`1` ""� Signature of Contractor 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 Sianature 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: (11 , 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 GOLDEN EA01sE INS. ; Policy No. NW -M4063-02 (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 subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shallJorthwith comply with those provisions,_4,-f �. Date: f x /�ti Applicant e� ��, A� .J/.Z: 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 applicator 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)/ = t. L.7, ..,&,1 Date k BUILDING PERMIT PERMIT# DATE / /i VALUATION LOT 001 1-20S TRACT $11 Wd 001 i S 27519 JOB SITE APN ADDRESS ,9_. X''l�R O DEL BEY�4I�-�I9Sl. �9 OWNER CONTRACTOR / DESIGNER / ENGINEER C"WRY Clrko A%aL C;C'rIAQMM3T..i i1W9 CRNTU:IaY GROWK► L COMS1?.INN '1 1533 SO. I'D" MTiWT, 311. 02©0 1535 so, °v� : T. Fm 91200 SM MWAR D1I O CA 92 08 sa.W AER1'JAR1 INO CA. 92408 (909)381-60(7 CRUZ 2120 USE OF PERMIT MSCiI.,iG. iA LY T?VilMd+NG SYD r Lt)T 64 i LAW SORC PERMIT i)0?31+1OT rMCU)DO BLDCX WAIMPOOL •, 75% FRE 1 ZDUCTION FOR MUL1IPLK ISSUANCE OFSAME .PLATdTYPE TRACT CONMUC TION Z01Q.00 STz IJORCHMAT,10 49.00 Stt Cli4RAGE/CARPORT ('017.) $,I'13.217 ➢SMW= COST OF CONSTRUMUON 12 7, ,x{;3 POOM§'Zf�"+ .�a17 A1�'Y CONS'i RUC T16N. REE 101 -00( b l I.000 4it1�.�9 PIAN CHECK FkE 101-000-439-318 $146.03 F>j ECHA4dICA.L ME 101.000-421.000 S53,50 ELPA;TIUCAL FEE. J. 01-000-4204M Qt1 $11112 PLi3MD10 PER 101.000=819,-000 9146,`) STIZONO A1I0'7'1N FES • =ID 101-000-2,41-000 ORADING FEE 1011.0100-429.000 520.00 Ir UVELA)PEX IMPACT FEE 9U.8-TY.ffA L f.°iIMl'Ii1.TC7.'iO4 AND PLAM C'I3WIC, S3,i139.f�S LESS PRE -PAID F=, TOT'AL T':IR'TLWIT FEES DUE NOW ,6999 RECEIPT DATE// ) ✓ BY r DATE FINALED INSPECTOR . fj ✓( :sC...J� INSPECTION (RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs ?�$ Underground Ducts Forms & Footings CEJ Ducts Slab Grade (2(Z$ Return Air Steel 1212 S Combustion Air Roof Deck o2A Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation $��� Cv� Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wail Insulation Condensate Lines Party Wall Firewall Exterior Lath I -Z Cpfr-&--A— Drywall - Int. Lath 3(3p C9 _ _ Final _� o� BLOCKWA .L , PROVALS Final POOLS SPAS Steel Set Hacks Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines _ 2 1 Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral M; 1$ (f1C Pool Cover Sewer Connection /Z $ Encapsulation Gas Piping Gas Test �3 Appliances Final 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) COMMENTS: