0008-029 (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.�r--t, Exp. Date
Date ��F �'a� Signature of Cont actor -'
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 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 STA TF. FIA4D Policy No. 046-007M
(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 California', and agree that,if-l�should become
subject to t�h"e workers' compensation provisions of Section' 3700 of the Labor
Code, I shall forthwith comply with those proviisions
Date: f/A7�.= Applicant—
Warning:
r - -•"�
Failure to secure Workrs.,90- sation 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,orpursuant 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
y for inspection purposes..
Signature (Owner/Agent) r Date
BUILDING PERMIT PERMIT#
DATE ` VALUATION LOT 0?8 TRACT
t &440 II7M0 i 29457-1
JOB SITE /
APN
ADDRESS 79-6107..x_ €�C` l� &A 4)7idffA .iW iW
OWNER
CONTRACTOR / DESIGNER / EN (NEER
+mak EKY, .n�I:VI+t li{UGI V�dSPA
i{.K;9COM.i"Jtlfl> —1O
79-.295 RMC.HO LA Qi t ai DR.
79-295 RMC.`HO LA QUSA DSS,
LA QU-P, TA CA 922S3
LA QUIidTA CA 92253
''
(760)77 1 w1941 CBL41 2996
USE OF PERMIT
SINGLE- FA*_1vMY DW0`
St�f�.P1..A.1d; Ff.�1t I.G'i:`t-PEtlrAiffT DC3LS N4T'IAICLt1D� F;i1,,0C;� ?�.�s1.L Ott
POOL
CU«Ti'OM C014STRUCTION 2,924.00 St+
-
PORC"ATIO 235.00 SFS
(0,11AMIC, RPORT (Sig) 9.212,00
`
:1 ESMOI`XED C09,r OF COl'dS'MI7MON
240,117.10
P ERMIT FEESUMMARY
F—. a
i
Cow T tuct10141YE 101-000-418-000 51;133,00
PL,AWC" HECX FEE 101.000-439-318
1d ZC:H. 01CAL FEE 101.000-4.21.-000
t�I.1LC'f`RdC�.z, 1r0 '101-000-420-000 $169.24
101^000-419.000 $1133
9TRO1rJ0 MOTi0`N PER REBID 101-000-241-000 $u:0a
C1t I�lAiii !? .07. 101-000423-000 $�it;,t10
AL+^V'LLQpEfi IMPACT FL'>? !9+1
ART IN. PUlkIC PL.AC;) S - RESIE 701 `000455.000 $100.29
Sf.. B Tt7T..At C ONS'I'R.UG'TIOM AM PLAN CfMc' K
v,588.16 ;
• LESS PRE-FAII) ME S
$0.00 '
TOTAL PERI-- IMS MA NOW
$4,$N.76
RECEIPT
DATE'i, ,.
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4
Underground Ducts
Forms & Footings —
Ducts
Slab Grade Z—
Return Air
Steel
Combustion Air
Roof Deck j>
Exhaust Fans
0. K. to Wrap 1017
F.A.U.
_Z117
Framing
Compressor
Insulation p, %
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
OfPOC
Final
S SPAS
BLOCKWALL AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines _ / —(tea
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection W(
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final A or_
Utility Notice (Gas)
ELECTRICAL PPROVALS
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 zz/
Utility Notice (Perm)