0008-079 (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
�n
6740Y4 B J.i 1101
Date, ' `�' Signature of Contractor ` b
., �t.•,,,__,-fir ... � .
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). r' '
() 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 STATE 1±UNO Policy No. 046-00 i` Y4
(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 shat if I should become
subject to the Workers' compensation provisions of Section 3700 ofthe Labor
Code, !shall if,
comply with,tKose provisions.
Date:,— %/ )�" r Applicant
Warning: Failure to secure Workers'`Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1'00,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of,Building and Safety
for a. permit subject to the conditions and restrictions set forth on his
application.
1. Each'person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have.read this application and state that the above information is
correct. I agree to comply with. all City, and State laws relating to the building
construction, and hereby authorizeNpresentatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent).
BUILDING PERMIT PERMIT#
00 -a19
DATE ; VALUATION LOT TRACT
9240,11.7;80 51 29457-1
JOB SITE t
APN
ADDRESS v -74s 17#1wano teA Qt!mEB..Dum
S►> OO�E"�1<:i
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Wy"Xs CONSMUCM :ON
GOWNWallox
79-2951ZMCN.O LA QU N1'ADR.
79295 RANCHO LA. QV11U.4 D&
LA Q17ZI` A CA 92253
LA QUIN iA CA 9225.3
(760,1771.1941. CBVf 2996
USE OF PERMIT
S1+9"I>L.,OT 31 PLAN 1,?ER, a PEI MI'T .DOE.S'NOT 114CL,UID& &LOCK W.Al.t, OR `
;)001. '��6 PIAN CHECK FEE R1'DUCT10N FOY, MULTIPLE' 1981 ANCE Or'
SAME PL.A1d "I YVE
CUSTOPA CONSTRIXT1O?J 2924109 Z1;
PORCH/PATIO 235.00 Sly
Q& RA0W-.ARPOR•T ($F) 9,212,0
Fy.f?11l"'3'w) COS"fi' OF CONUMUCTION
240,117.10
1PERAW IMF, SUMMARY'
CONOTRUCTIO'N PLIE 101=000-418=,000 $111.113.00
PLAN CHECK FEE 101-000-4-:39-318 $232.:
MECHA141CAL FFE 101.000.421-000 SIX50
ELECTRJCAI.; F1?,Z 101-000-420-000
Z'`_ {
PLU1• DR413 FFX 101-000.419.000 505.79
STRONQ MOTION FER • RESIU 101-000-241-000 92$.01
� !
GRADING PEE 101.000.4.2:3.000 $20.00
I)EVELf)PER IMPACT iEE
t
AR.T IN PURI C PLAC09 • RF.11L 7011.000.255u000 $100.29
�.
�� ;— .
SM -TOT At, COXA TrRUC 1 04 ANLL PLAT CI.MC:11:~
$3,892.03
-PRE AID ' r -S
X0.00
TOTAL r3ffMUT 1 FEES DUE, NOW
RECEIPT+DATE
BY'
DATE FINALED
INSPECTOR
_a..,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/z�—�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
— .p
Exhaust Fans
O.K. to Wrap
�_�6� /`
F.A.U.
Framing
�_ _�/a ��
Compressor _
Insulation
�,('
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
ot
Final 7T�00--f —ZlC01—
Final
POO S - SPAS
BLOCKWA
L APPROVALS
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—
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
�z �3���7
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
7-1
Appliances
Final Final
COMMENTS:
Final
J
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)
O