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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 Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date ignature 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).
( ) 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-instire for wo rkers'
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.
ST ATIT , RJNLI 1'�471(19.594
(This section need not be completed if the permit valuation is for $100.00 or lessy.
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 th�e workers' compensation rkovi�sions-of Section 3700,oPthe Labor
Code,lshal . I forthwith comply with those provi'-si�ions.
Date: I ; / �f Applicant—
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 the above information is
correct. I agrde 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 propertrfo-rinspecti'on-purposes.
el _/r, �
Signature (Owner/Agent)" —Date
a PERMIT# CONTROL#
10 1/1�7 BUILDING PERMIT wormll.0i
4063
DATE 1.1 VALUATION LOT
JOB SITE 79AW CARINIEt, ORUAI',
APN 60_21014WS
ADDRESS
I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S" A RIVS C 1111WC , N
14t ' 'ONM 710
Cl, BOX i, I(;
79295 RANCHO LAQUINTA DR,
I -A QUINTA -'A 'L 2253
LA. QUINTA C A. 9 22 5 �3
019)771-1941 2996
K�WZEK-CRANU-IL, INC,
USE OF PERMIT
AN(.:4tJ,.' VAMA'DWHAANG
OP.:
I AL1r7rnPVQI' 0A 0'W10
PLAN t PA1,Af-10 1',RACn,2795,52 -1
ARTIN WMACMACE5 171W.MY OF
$465,74 t%-Vrfv10T-%FKNT
CON'lViINI fX4NKfk(TCTf(3-N 3.465,00 XF
PORCUIPATIO 335�00 SF
QARA01VCARP0Wr 6018-00 -sr.
EXCIMATRU) COSTOF
286,295.80
PLAIN 0,1ECK f -TE 101-WA39-318 $1,065.95
CONSCRUCTION'14-Vi 101�000.418-000 $1.2cm-ok,
M3,A3 4 AN I C A L F1 1, 3143.50
r, I - 1. Z C T R I f " A I I " 9 T, 10 1 - 0 4 4) - 0 0 0 $213.44
PLUMBINIC FF_E 101 �=M 19-000
ST N j.4
01 GMMON RE. - 11diS1W 101-000-1 11-wo S2&O
G'KAJ)ING, RM 1014*4234)0
[NMANIT.RilcrURF FVF 225A,04143-142 S60'.0m.00
PRXICISEPLAN 101�900441-345 525"go
AWt IN PUBLIC PLACI�S - W5,74
".80, '1.01-0W4S5.0W -V65.74
17AL CON 1,T1'RUCT110 N 4UND LAW CHECK
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RECEIPT
BY
DATE FINALED
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
ExhaustFans
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
E)derior Lath
Drywall - Int. Lath
I
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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 4Z 4- bk-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Urxierground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)