0210-014 (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. Dated 1
6x'744 4 RFUC �f %7131/03
Date' v 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 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 $? 1>s'f'R YUNTJ Policy No. ' 046-t32G�13 ?` 5
(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 I should become
subject to the workers' compensation ,provisions of Section 3700 of,th � abor
Code, I shall forthwith comply with;those provisions:' i moi`
Date: �' ' ' r� Applicant,Y _A �-
r
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. a-
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 Inspecti'o purpose . r
syr ;
Si nature (Owner/A ent) Date.
PERMIT PERMIT#
.BUILDING 0210.014
DATE VALUATION $ a 0 LOT 1 TRACT
29ci45d r
1 7.5
1t..' .✓ r'a0�iil.3t3
JOB SITE
ADDRESS J S7N. ar6l�rcie� a,kS �1�7 1Z1ai+%I<',
APN _
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'M Dil%S1E3°r .1%` MM 0PMEff
SPARKS 00149 'RIJah:ONN
F0, 13OX 1716
7 9-295RANIC,1110 LA QtYMA DR.,
LA QvbTrA. CA 92253
1,A QUT 4 TA. CA .92253
(mCyn-1-19un G'}m* 7..996
"
USE OF PERMIT
S 10123 '`.fb.1MM
Sf- - LOT 11, K ICANTO 2. PPAIIT DOR; INCIT DIcLtw D110I..00K
WA ,146 POOL, SPA. OR .DR1i+' WAY APPROACH 75rK PLA79 OWK 1r?,9_
i• YDI:i TION 1c Vk MULTIPLE. ISSUANCE OF SAME T IA11 T YPE, �
0118 OM 0a;ISTRUCTION 2,024.0D.0
PORCH/RATIO 3S:OiJ ;
[IARAMCARPOR'r 4'YIti, 8P
:14; 3�1'►f t 3) COST' or CONS 1,'"E7d'i"'C:".k°ION
24t),117,16
COPSTR1Fd TION !!`EE - 101 -OW -438-000 51,131.00
PLAN CHET- C IMEE 101-000439-318 =r4,7A
fiRWI A1I1t JkL FEE 101-000421.000 $170a5a
rL �a;.'CWC:1'.:L I? ZZ 101-000-420-000 S l 69. Z-1
Pi.'€Iia11'1INO F4T.t 101.000•419-,000 $175.75
S TRO1.40141OTION Fri, a R-ESID 101-00-241-000 $24.01
11R.A.W N0 FEE 101-030 -423yfit10 SI a,00
DEV F1.OPFR IMPACT F+I,Z $2005.00
.AXf IN P"UBLIC b'lAc`'PM - RISdi 270-000-445-000 SiO4.."
II% W iii,, COMMUCTIC11,1• til D PIA': (,Mk,—`IX
$4, 3tsS.03
S?: ;E"I`'AICa'YTOiN
$0.00
Y�
PD
OCT 3 v 1002 L
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RECEIPT pY. DATE FIN LED INSPECTOR
FINANCE a. tT.,7
ro �
9 9 ,c. ,u t
INSPECTION RECORD
A/
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs ; I
Underground Ducts
Forms & Footings i 1
— —
Ducts
Slab Grade 11
,2 — — Z
Return Air
Steel ; {
Combustion Air
Roof Deck 14
— _ 3
Exhaust Fans
O.K. to Wrap ii
F.A.U.
Framing ; t
p —3
Compressor
Insulation f 1
g — 3
Vents
Fireplace P.L. I!
-
Grills
Fireplace T.O. !
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall !1 I
Exterior Lath ! I
Drywall - Int. Lath I
_
i1
i I
Final
B.LOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs I f
Electric Bond
Footings I'
Main Drain
Bond Beam
Approval to Cover
i;
Equipment Location
':
Underground Electric
iI
I
Underground Plbg. Test
Final 11
Gas Piping
PLUMBING APPROVALS
t
Gas Test
Electric Final
Waste Lines ; i
_ = 2
Heater Final =
Water Piping ; I
Plumbing Top Out i
ZQ 3
Plumbing Final _
Equipment Enclosure
Shower Pans 1
Sewer Lateral ] j
/
O.K. for Finish Plaster _
Pool Cover
Sewer Connection—l72
Encapsulation
Gas Piping f±
-
Gas Test ]
Appliances 1
i {
Final
Final ];
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole [
Underground Conduit
Rough Wiring I I �Q 3
Low Voltage Wiring
Fixtures I!
Main Service r
Sub Panels ] I
Exterior Receptacles
G.F.I.
Smoke Detectors I i
Temp. Use of Power
1 I
i
Final {
Utility Notice (Perm)
COMMENTS: