0008-035 (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 '7 r/4'# Signature of Contractor
•
OWNER -BUILDER DECLARATION
i'
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).
(") 1, 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 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 STATER FUND Policy No. 046,0007333
(This.sectiori need not be completed if the permit valuation is for $100.00 or less).
O 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 that if I should become
subject to the workers' compensatiori provisions of Sep6on,3700 of t: a Labor
Code, I shall fofrthyvith comply with'those provisions.
Date: Z!� r'j "�•`' Applicant f tt
Warning: Failure to secure Wo Iters, Compensation coverage is unla�rvful 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
appliunliurl.
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 thisapplication 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 ity to enter upon
the above-mentioned property for inspection purposes:
t. 4/ 1 �[
Signature (Owner/Agent) -'' /Date rt , `
BUILDING PERMIT PERMIT#
0"_W
NS
DATE j ¢¢ VALUATION LOT
7 TRACT 29457-1
t t ) f / F•F {
JOB SITE t / '
APN '
ADDRESSRANt;T101A,QMMA.D.R
64S} 00-019
OWNER
CONTRACTOR / DESIGNER / EN INEER
131;"= C014MIZUMIXON
011aW C0MFfR7: CT.i0A7
79.295.RNCH0 LA Q rtA DR. .
79-293 RI MCHO LA.QtTWA DFL
L.AQUI TA OA, 92253
LAC 1MTrA CA 92253
(760)771.1941 CBIS 2996
USE OF PERMIT P, J
SY0•L,:i'T 7 PJ.,AN 91 R - PERMIT L)tSES NOT 1xdCLiJnn; su r. '6+i:AL.L OR
POOL. 115%PJ AN 014+);.f.`K FECREDUCT.ION 'OR M.ULT11 M ISSUA14C F,OF
SAME PLAN TYPE.
'CUSTOM CONSTRUjti TION 30635,06 5F
PC;E2CH/PATIO 267..00 SF
C: �AltAGEIC.ARPORT (M), 12,034.40
XY A.',Y'.N:Y) COST Or''CO.NS=UC'nON
2200.52.00
M"r ](PI'M SiLT", RY
CONSTRUCTION ME 101-000-418-000 3.1,063,06
PLAN CH E.0 X FEE 101-000.439-118 $237.90
t,IfECdTCAL FEZ 101-000-421-000
1_1= TRJCAL FEM )01 -000 -420 -OW $163.01
1~
PLUMB11140 FEZ 1011-000-419«000 $179,25
STRONG MOTIOW FEE • R MID 101-000-241-000 $2109
ORAD,NO FFR 101-000-423-000 $20.60
DE ,I�AMR JMPACT FEE
ART N PUBLIC PIACE0'- RUESM 701.000.255.000 352,13
E;UB-TUTA1, CONRRITC"10N PWD PIAN a]FP-.Z
$3,728.38
ISS ;PR't•T)i3'J13 tnS
RECEIPT
DATE {
BY r^`
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_11-7
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
�—,�3_
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
��
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath000-
Final
A
/ b �/
Final
60OLS - ' PAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Locat' n
Underground Elhctric
Underground Plbg. Test
Final
I
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
'
/Z �J 6�e
Pool Cover
Encapsulation
Gas Piping
Gas Test
_ _ _
Appliances
Final
COMMENTS:
�'
�—
Final>�
Utility Notice (Gas) Jy�
ELECTRICAL XPPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. J
Smoke Detectors
Temp. Use of Power
Final
?o,
Utility Notice (Perm)—