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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 Bbsinesg and
Professionals Code, and my License is in full force and effect.
License c. C ass ��xt Date -
"I T 7,11
Date __�_-'Signature of Contract r
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).
( ) 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 Policy No.
.71'ATE FL NI) 1111110(IW4
(This section need not be completed if the permit valuation is fof $100.00 or le6s).
I certify that in the performance of the work for which thit permit is issued,
i i . th
I shall not employ any person in any manner so af to become subject o t e
workers' com, pensdtion laws of California, and ag�ee thpt If I should �ecome
subject to t�e wor6rs, compensation pr6visions of Secti 3700 of the Labor
Pdde, I shall forthwith comply with thos6 p16�isionsV
Date: I " i 1ADDlicant I _1 IA.- 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 permi - t subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose beh�lf 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 w 11 subject permit to cancellation.
I certify that I have read this application and siate Tat theiabove information is -
correct. I agree to comply with all City, and tate/laws r lating to the building,^
construction, and hereby auth&i1e rq'pre reen atives of is City to enter upon
Al I
th bove-rtientioned property for �n purposes.
, I - (. %_
7
Signature (Owner/Agent) Da'
te
. f
BUILDING PERMIT
DATE 12, 1 oejw VALUATION LOT
JOB SITE
ADDRESS 78-951 CARMEL CIRCLE
OWNER
T 1.). Pllisl,-, It'll Df-VI'L011%Mtri,
(3. i VIK I
LA QU IN f'A (,'A
USE OF PERMIT
t0,1Nft'A,'�1Tl11kf, At RATION
ADD "O&F,
PERMIT # CONTROL#
96114114#4 TRACT 4461
33 2,P) 5.1
APN 649-2 10-05
/ DESIGNER / ENGINEER
SPARK'SCOIll" 1'ZUC-r10-%1
/929 5 !Uk NCI 10 LA QUINTA DR.
I,A QUI IVIA CA 4225-1
HIWGIA-i - CUSTOM 11.6214,00 SF.
o.1KC,1 wwrto 210�011 sil
EM11VIATE, D COSTOF CQNSIRUCITON
PiEkAUT FEE SUM MARY
P1. A N C I I EC K 1; r, H
1014)(14*318
CONSTRIK7170N FEE
Im-wAIR-ow
S 17 1,00
XWOIAMICM, FEE',
10 1 -000-42, 1 -(X)O
.I.E,(�TWCAL FER
20- 000
$ 2 1.
IN M-ATll'RLF01_Wt F$ -_H
22S-Offl-410-142
$261.0
SM)NO MOTION PR, - RESIO
10 140)-24 1 -(W
11.52
sulvioll.t'u, CoN�$,Ilujcn c-) NAN* ei..AN a.w.cK
CITY OF LA Q LESS PRE -PAID FUS S0.00,41
UINTA
TOTAL PERN41T FEEN IME NOW S."I'60
DEC
4 FINANCF nr=pT
RECEIPT DATE BY PATE FINALE D
INSPECTION RECORD
OPERATION
T DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs Lk"
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
UU14 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 -
Utility Notice (Perm)
COMMENTS:
6-,17-67