0008-041 (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
617407}43/ �7}1ID1
Date tiff2� Signature of Contractor
OWNER -BUILDER DECCAR TION '
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 affir 7 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 FV)gt) Policy No. 0415-0007338
(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 Californl�, and agree that if I should beypome
subject to the workers' compensation pro Iv sions''of Section 3700 of the Labor
Code, Is
forthwith comply with those provisions. y�
Date: Applicant t f
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 representativesro this City to enter upon
the above-mentioned property for Inspection purposes
Signature (Owner/Agenfik
ZDate d 4 6 "5'
BUILDING PERMIT PERMIT#
����-��
DATE VALUATION LOT TRACT
$240,11,7.10 13 29457-1
JOB SITE 1
ADDRESS 79- 7.V..1.ZANTCiHOLA Qrfj 7T«9.1 }.iTVE
APN '
4-1Q30-flI�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
aP/. s CON8'1111ur- CON
SP :,8 C0952.UC".tION
79.295 iRANC.H'O 1A ( W14TA DR.
79-295RANCHO LA i;?1 WTADI2
LA QUINTA CA 92253
LA Qli'T1 rA C.A. 92253
(, 60)771.1941 CB110 2996.
t
USE OF PERMIT
MOLE— FA LY JAYRX:L,1NG
�
31?D..LGT 13 PLAN LAR • AI.t,'RMIT• DO&S NOT INCLUM 0LOCK WALL OR
POOL. W/o P,LAW CHECK FFA i3F UCTiON FO 14Ii UfIPL ISSUANCE OF'
:irg M PJ AN T'm.
CUSTOM COMTRUCTION 2,924.00 Sia'
PORC HIP.A'JO 235.000
GARAWs"A ?.PORT .(9l) 91212-00
t.i,UMA C -03'f Olt Ct).0i4;f UC7T 14
240,117.10
CONSTRUCTION FEE 101.000-418.000 $1,133.00
PLAN CHECK I`L�1:. $232.24
MECHANICAL _.X'E1± 101.090421.000 S130160
ELECTRICAL FEE 101-000-420-000 5S162<�t.0;da1
PLUMBIN(FRE 101-000 -419-000
4A.0 rOrt1t
R
STRONG MaYION F7,11 R. ID 101.000-241-000
GRADINO PRE 101-000-421-000 MAO
;Z9
DLrVLLUPXR IMPACT FEL 1,94?.00
Pwt t .
ART D.4 PUBLIC PLACE • MUM 401.000-x33.000
WD -'TOTAL CON'iS".i.' UCTION AND Pi AR C l C:K
$3,092:03
LFS.) PRE -PAID FE,1~59
$0,00
'r9rAJ6PM4XJ7.J—SDUJE NOW
RECEIPT
DATE p
BYJ'//(r !
DATE FINALED
INSPECTOR
INSPECTION (RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs9_���
Forms & Footings
/
/ i�
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
2
Exhaust Fans
O.K. to Wrap
_
?F.A.U.
Framing
�–D
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
Final
–_— �
Final
POOLS - SPAS
BLOCKW/�LL
PPROVALS
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
Sewer Connection
�c3
Pool Cover
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)