0008-049 (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 myLicense is in full force and effect.
License # _ Lic. Class Exp Date
67,07$ B 7A1101
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:
( ) 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to, constructor 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 arid 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:
Carver STATE FU14D Policy No. 046.090`9'332
(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 mann'erso as to become subject to the
workers' compensation laws of California, and agree that if..l•YshoyId become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provision's.
Date:t f� Applicant
.I'
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.
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 -t a above information is
correct. I agree to comply with all City, and State'lawsrelating to the building
construction, and hereby uthorize representatives of this City to,
enter upon
the above-mentioned property for inspectiontpurposes. ✓l f
Signature (Owner/Agent) ��/ ! ! Dater�4�
BUILDING PERMIT PERMIT#
DATE VALUATIONLOT 0"-049 TRACT �
$24v,,117,1U a i 294,57.1
JOB SITE
ADDRESS . r 8ai RANC13i0 LA S�UINTA Ii .E
APN
649-10li-019
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SPAM CONS'iT'P=11014
SIPAI = COA STRUCnox
79-295 RANCHO LA QVINTA 7711,
79-295 RANCHO 1A Q'UTDM4.Old
LAC,QLTWTA CA 92253
:LAQU N'IA CA 92253
(760)771-1941. CBIX 2996
USE OF PERMIT
012 17A3MLY 7:}'1 AIXR 0
i
Sim -LOT 21 PLAN N2R - PEI3WT r0rS N&r INCLUJ)Xe BLOCK WALL OR
POOL. 75% PLAN CHECK FE4REDUCTION FOR MULTIPLE IWIJAWCE OF
SAME PLAN
CUSTOM. CONSTRUCTION , 7¢24.00 OF
;PORCHWATIO ' 33'5.00 aF
GARAGV('ARPORT (I3F) 4,` J2.00
k1siIMI IUD Coyr O%` C3ONS'TRUCnom
240117,10
1P7:..R1VIi`T' Fn SUAGIA"Y
CONSTRUCTION IRE 101 -000-4'19-0500 51,133.00
� t;
PLAN CHECK YZE, 101-000-433-315
MECHANICAL FEE 101.000-421-000 $130,30
ZLECTRIC'AL FEZ 101-000-420-000 $169.24
PLUMDINO FEE 101-000.419.000 075,75
S'T RONO PACITION FEE - RMID 101-000-7.41-000 V4.01
ORADING FEE 101.000-42:4,,•000 $10.00
sem.
DEVELOPER IMPACT FEE, $1,907.OQ
G �
ART IN PUBLIC PL.AC1919 - R.EfSIE 701-000-255.000 x100.29
PUB -TOTAL (20NOTRUCTION AND PLAbi' CBECK
$3,892.03
I. WAS P72FI-P. AU) FM
$0.00
'IMAs PI.1`•tOlM FY.ES M-0 NOW
$3092.011
RECEIPT
DATE !
BY,"
DATE F ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
_Underground
�
Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
Roof Deck
O
Exhaust Fans
O.K. 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. Lath-
`^
Final
Final U
POOLS - SPAS
BLOCKWALLA
PROVALS
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 17-2,Y-01
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/
Encapsulation
Gas Piping
Gas Test
. Q i
Appliances
_
Final
COMMENTS:
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
Temp. Use of Power
Final
_Dl
Utiljty Notice (Perm)