9907-078 (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. Date
6_7474 it / 0713V19,
Date I` �_ Signature of Contras r
OWN ER -BU ILDER.DECLA\RATION
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).
( ) 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:
Cartier Policy No.
ST -ME FUND 046-0007331
(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 should become
subject to the workers' compensation provisions�ection 3700 of the Labor
Code, l shall forthwith comply with those-povislons.
Date: / /r Applicantif ✓o ( -�" '
�/�:� 2
'✓Warning: Failure"to secure Workers' C mpeation coverage is unlawfu)l and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. ,r;r
2. Any permit issued as a result of this application becomes null and voi&f
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is- Vim.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represerLttatives of this City to enter upon
the above-mentioned propertfy for inection pp r 0 S.
/Signature (Owner/Ag/eennt)���f � �" - Da�/ `5�
BUILDING PERMIT PERMIT#
"0i-Oig1
DATE VALUATIONf 0. !wf<t46 jj) LOT �'/ TRACT 25i �4
ADDRESS t" �'^7o ) RIO SRO JoBbITEr
Y
64&331-01.9
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SPARKS s~ ONS'1'R "UMON
130 rs0 1716
79-795 RANCHO Lik QU[NTA, D.R.
LA t)U NI -A CA 92253
I.A QUrifl`111, C.,A, 92253
(76f !)"I 1_.1941 CBLi# 2996
USE OF PERMIT
SINGLE iFiWILY [aiEl, UNG
SF - "(,OT 2-7 P{.&,q V 1'3s -Oa2 a,r Doss NOT 'tNCLU0 ..BLOC'% WALL
Cil"t,1�Otii,.
w
V^Ja:rolm C Uz4STIR C POIN 2038.00 Sr
0Al2 VORYC;ARPOR 73$,00 S%
&4511111XIIEM COST OF CONSTRUCT VON
SUMMARY
C,'i NSTRU4;'1'IO1etF:EE 101-000-419-0) �t3yH.Sli
VLA2S 04P4K 14T" 1(I140;11.39A318 $71115
A11r:CUAT41CAL F0 101-000-4.21-000 553.60
M, "'iitICAL F09 1131 -OW. 42&,00 S.1:34.9ss'
PL'UNIB1NG k EW • 101-000-419-000 S136.00
R111 . pNf M ('l:QN F Ott a[n !(r,+.-000-241-000 $19.32
GRADING FEE 1:01:-000423-000 $20.N
i1•.[i-1W&I`R.t1Cn'€lM', iL 225-000.4,43-342
ART IN .PVBL*1C" K.1AC'.ES - RESIC-. ,701 -WO -25 5 --ON 51 S 1.(15
kSIJ-'r(Y,I'A1-.CONS")Rt,10110NAtN1? 1•'1.,AN CHECK
$fi,063.q$
,,,.. I -ESS PRE -PAID P.1TES
$0.00
MYCAL PERMIT fi'i E -S 1 IM, NOW
$6,063.98
��• .,.i a. /SEP
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
GC
Underground Ducts
Forms & Footings t
(
Ducts
Slab Grade _
Return Air
Steel
Combustion Air
Roof Deck G . _
Exhaust Fans
(,
0.K to Wrap e,,W
F.A.U.
Framing ef• ep
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
Steel
POOLS - SPAS
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 ,�—
LGC
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
Utility Notice (Gas) G U
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 ao
Utility Notice (Perm) — 7 - C -C-/
GlL
COMMENTS:
_