0008-040 (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
Date fY�' t°)^•� n Signature of Contractor
r , f •.
OWNER -BUILDER DECLARATION,
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 & Prof essionals•Code).
( .) I, as owner of the property, am exclusively contracting with licensed
contractors to .construct the project (Sec. 7044, Business- & Professionals
Code).
() I ani exempt under Section B&P.C. for this reason
Date Signature of. Owner
WORKER'S COMPENSATION DECLARATION
1 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 3T00,of the Labor Code, for the
performance of the work for which this permit is issued..
( ) I have and will maintainworkers' 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or: less).
( ) .1 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 (..should become
subject to the ;workers' compensation'p o isions�of'Sectio 3700, f`the Labor
Code; l 'shalyforthwith comply with those provision`s.
Dated %} `' Applicant 3
Warning: failure to secure Workers Corrip nsation coverage is unlawful, and
shall subject an employer to criminal penalties.and civil fines up to .A00;000, in . -
addition to the cost of compensation, damages as provided for in Section 3706:.
ofthe 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
appllcatlui I.
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, representatives of this City to enter upon
the above-mentioned property for inspection purposes '
Signature (Owner/Agent) •j ''� Date
x
BUILDING PERMIT PERMIT#
DATE f VALUATION LOT ��� TRACT
1 1 1 'I l r'.r °d gT;kef 29457-1
JOB SITE' 0
APN
ADDRESS
79.-M RA NCUO LA QVIN; A DRnM.
.649 IMAM. '
OWNER
CONTRACTOR / DESIGNER / EN INEER
7 9-295RA19010 Lh QUWA IDX
La::,QUINTA CA 92253
lAQf3iWA Ck 92253
�'00>771.1941 j a9l* 2996
USE OF PERMIT
31�vr4G 1.7,'ff.; 11��d1<?r
SP. -D- . r *1I' P .i?N 9 1 R - PERM I .00PS 1.dOT it4CLU DE atIOCK WA:t..i. OR �
POOL 7$%'3:,1 N MICK F FE RB1rXJc,rx0w7oR Mkou Y"�..� IOSII.RH,0 OF
CUSTOM CONSTRIJ0't 11041 a,auo SF
ft)RCHIPATIO• - . . 267,00 S
'110AGM-.t PPOR1(In
1�:�"'�1'XA�9;a C `air' G:tJt!fi�u"2�'�4'",�7:�?i�]
.XA
1W.KWIT1,11M SUMMARY
t" �C,NS7'YWICTION Fta,9 301-000-419-:000 $1,,063.00
+qq�LAN REE �2�pb�^
��7 ��mmiiSy[�...y�l,�pp9yE.�.vCppKxp��tA�'9'3/��/��,�hs,
E76 &.•6L1slY,I6tA'h,3.i HaiE - 101- `004,61-000 •V J.ViA,VN
t�.4 W
.Ix�:GT ' 101«ClIJ0.42U-(Jfdt1' iti .fit
1 -
M
PI<UMBINO I;t:E $179.2
S rF,c.140 5IC' ION .FE N RO-SID 1 0) X00-2.41.-000
DEV1110PER IMPACT! FEE
:'AR'.1IN I33� `YZ. C::i ^ It 1) 7€1'I.;�►OG;,,25 CIC J
-
"3
T, 1
r.13S9 PRE -PAID TRIO
$0.00
r0TA.L?LHAHT r ns D% ow
RECEIPT
DATE ft
ri'�
BY /
hj
DATE FINALED
INSPECTOR
J
r.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/'_ _
"�`�-�
Underground Ducts
Forms & Footings
!
Ducts
Slab Grade
j� _
_60-
Return Air
SteelCombustion
Air
Roof Deck
�—.S D%
6_
Exhaust Fans
O.K. to Wrap.3
Z—D(
6
F.A.U.
Framing
3_S�/
fj'
Compressor
Insulation
��
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 7 %
J�Zl�
Drywall -Int. Lath
"'
A�A
[[`J
Final
�_
Final
POOLS - SPAS
BLOCKWALL PPROVALS
.
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
ial
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
'
/'
Pool Cover
Sewer Connection
G
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
7Le�
.Utility Notice (Gas)
C �I
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
_ 2 `-
Final
�vQ
Utility Notice (Perm)