0008-042 (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 -D to
01
( Erc✓
Date r Signature of Contratctor
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 1project (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 undergpenalty of perjury one of the following declarations:
() I have and will mainta n dcertificate 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:
Carver STA.pE 1'IWND Policy No. 04640f1i330
(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-forwhich this permit is issued,
I shall not employ any person in any manner so as to-ybecome subject to_the
Workers' compensation laws of California, and agree tHat if I should ;beco?ne
subject to the workers' compensation;pro'visions of Section 3700,of`the Labor
Code, I shell forthwith comply with those provisions.
/. ,., LDate: ' Aor licant r •1
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.vauthorize representatives- �of,this City to enter upon
the above-mentioned property f reinspection ppose's.' ,
Air i /a d f ..
Signature (Owner/Agent) 4' `" Date'' t1 fr. a• .
BUILDING PERMIT PERMIT#
DATE '_ f VALUATION - LOT � TRACT
L9457-1
17,10 14
JOB SITE
APN
ADDRESS _740 RANC,Hp.;!..A;QUY1T.1"A1?ZZ' X
OWNER
CONTRACTOR / DESIGNER / EN (NEER
VAU1 13 CO NS`.['rIUC7 014
SlW&B CONSTf:I;74)IN
79-293 RANCHO LA QUWP. DR
'79-295 RAN(MID 2:.A +Qui fA DX
LAQUINTA CA 92253
IAQU CA CA. PtI53
(760)771.1941 '' CBL# 7,996
USE OF PERMIT
SI1rK1Lt lf'.lA1'ALY D%ti1�.?WXC
SPID-LOT 14 PLAN 921, • PER]MIT VOM NOT INCLUDE 81 K •WALL OR. i
POOL.. 751K PLAN CHECK PER PJi'DUC1 IOW ICOR MULTIPLE ISSUANCE Of'
SAME PLAN TYPE.
CUSTOM CO'WSTRUCTION . 4924,00 SF
PORCWPA T YO 2:15.00 SY
CdAid.AID U CARPORT (3F 9,212.00 .
y:
f TVA
XS'MA11'D COST OF CONS`.t1RU'010N.
240,117.10
i0iMfr Fn SUMMARY1"
r'
L$1,133,00C4ASrRUCf1CN9Lf
'
-,
PLAN CHWK FEE 101.000-439-318 $232.74
MECHANICAL FEE 101-000-4121.000 $130.50
ELECTRICAL FRE 101-000-420-000
t -
PLUMEITNO reF9 lol.000=419.000 $176.75
STRONG MOTION FEE - k=D 141.000-241-000 $24.01
CIRADING PER 901.000.421.000 $20,00
�a
DWEL.UPER IMPACT FEE 31,907.00
ART ?N PUBLIC €CLWE' - RES1I 701-000.255.000 s10a,29
ak7B-'.t'f3'T'AL CQAaS1::(d1')'MCaN ANI] .PLAN CHECK
:3,592.03
LWO x?IZE-PAID 1�1 FM
$0100 _
f
RECEIPT
DATE
BY �' j/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade — / —
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. lath
_
Final
BLOCKWA L PPROVALS
Final
Steel
POOr` -SPAS
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 001z-Z-97Heater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateyal _ /
Pool Cover
Sewer Connection(i✓/
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) O
ELECTRICAL PPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels 11,01
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: