0008-081 (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 # ff Lic. Class Exp. Date
Date 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 Siariature '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:
CarrierS`�ATE MUM). Policy No. 046-000`x33
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) (,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,Califorrrl and agree thatNif I should become
subject to the workers' compensation pro isions of Sectiont3700 of the Labor
Code, I shall forthwith comply with those. provision & j
Date: 1 r °%f E% Applicant
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
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 f' .✓
Signature (Owner/Agent) + Date/// � o
BUILDING PERMIT PERMIT#
(9)0&4D81
DATE f VALUATION LOT TRACT
/,., ' 53' 29457-1
JOB SITE r
APN
ADDRESS 79-715 P%ANCHO LA QTwrA!?1RlVE
649-1,00.019
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SPAS C014W RV CrrIO1,T.
5PARX8 C,ONSTR2iUC' OH
"79-295 1W.WHO LA QUJ 1.A DR,
79m2951ZANC'•IT0 1A QirWA DIRL
LA QI1TA OA 92253
LA QUM-TA CA 922$3
(760)171.19.41 CB1_A 2,996
USE OF PERMIT
"990 12 FAWLY la' ]HJ J23G
SFD,LUT 53 PLAN KIP,- PERMIT DOM NOT INCLUDE 13LOCK WALL OR ,
POOL, 75% PLAN CHUCK FFX REDUCTi IO14 FOR I19UtJ IPLE ISSUANCE OF
SAME PLAN TYPE. •�
CUSTOM CONSTRUCTlOPi 2,9284,00 SP
PORCKWATIO 235.00 3F,
O.ARAGE(CARPORT (81� 91712.00
COWT O!I' C0fi9MUC'1<T0X
240,!! 7 2.dD-. • �
y17MATKD
spy a ry v�, c•� gE�9
.L-�r.lY�.�..Cd� ►7 V.iC a
p,� Kti �j Z..
CONSTRUCTION PEE a 101.0004418-000 Ei,133 tit3
I'` #
PL,aN CHECK: FEE 101-000.439-:318 $233.24
MECHANIM FEE '101.000-421.000 $130,30
R1.ECT R.I.CA , FEE 101-000-4.20-000 $169.24
PLUMBING WE 101.000.419-000 11`WS
t:'
STRONG MOTION PEES ISI® 101-000-24`I-000 $24.01
GR11.1' DID PER 101.000-423.000 s2ti,ii0
DEVELAVER IMPACT FEE $1,40°i.00
ART W PUBLIC PLACC� - RES9ii 701.000.25.5.000 ((100129
&IFB-TOTAL CQ9MM7110WlPY. AW' QI ECK
$3,€492.03
!E9S ME -PAW FFM
$0.00
S'VIAL F• 3W.r MS DUYK 14 OW
. .
RECEIPTa� DATE`(
BY �Jr /
DATE FINALED
INSPECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
"
Ducts
Slab Grade
Z— Z 7 eo
Return Air
Steel
Combustion Air
Roof Deck
3o_p
Exhaust Fans
O.K. to Wrap
Framing
F.A.U.
Compressor
Insulation
-1
�_�/p
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
— 6 -
BLOCKWAL_L AVPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines)
��g�
Heater Final
Water Piping
/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral���
Sewer Connection
r
6 �O
Pool Cover
Encapsulation
Gas Piping
Gas Test
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 i
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: