9907-077 (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 # LLiic. Class Exp. Date
674074
ate Signature of Contrac or`
OWNER -BUILDER DEGL-ARATION
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 constrLICA 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 affirmunder 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.
(� )r 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. _
,STA'1'Ia..FWr'D. (146M0.7333
(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 s uld become
subject to, the v/�orkers' com ensation pr visions of Section 37-
V.
of the Labor
Code. 'fall fdrt with comply with thoswprovislons.
ate: �� /sApplicantarning: Failure to secure Workers' Co�mpen-��ti n coverage is unlawful and
shall subject an employer to criminal pena—Ities and civil fines up to $100,0 0, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
_ r
IMPORTANT Application is hereby made toYthe 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 agree to comply with all City,.and,State laws relating to the building
construction, and here by-•aGfh�orizeoorepresentatives of this City to enter upon
the above- mentioned/propertyy for inspectionUp rpose .
,.Signature (Owner/Agent)
BUILDING PERMIT PERMIT#
' 9907•077
DATE VALUATION .13,7.3.40 LOT 26 r TRACT ,25154
JOB
ADDRS11ESS 179-940 P.10 SCO
APN 646-331-004
`
OWNER '
CONTRACTOR / DESIGNER / ENGINEER
TD. 0H'SBRT_i.71'V 1,0:1'N!KtW
VPARKSC0N9f':tJCTfQN
1'C► BOX .1716
79-295 IUVNCFI.O .Ltd. Q'UINgA DR.
LA Qe,3M'I A CA .922.53
LA Ql i'1 N :1'A: CA 92253
(760)'771-1941 C.:`.'K;h' 2996
"
USE OF PERMIT
SINGLE PAPd1.it,Y DWELLING
SPO-.I:tsT 26 PLAW ` 44Z - PERMIT DOWS NOS' W(',� 1UD..R LILO K .WNU
CUSTON41 *1566.00 ,4'k
PORCYNI A 110 80.00 Sri
GARAWCAMICA', 655.0 S
,
WrI&LA` EM € OST Or, CONSTIRUCTION
213,7M.40
P :1%!t'il.ff FEE SUMMARY
(:('aNISTIZIlu'TIONFES 101-OW418-000
101-000-439-318 $849.44
N<<I3 CHANIC',A1. FIN 101-000421-000 $95:513
1 L CTRIC'AL RM 101-000-420-000 .$167.91
Pl l mal.w rFE 101 -NO -4.19-000 S161,VV
&1'.1ZONG V101,'10N P ?3 - RF381C} 101-000-241. -000-2414NO $21:
CrRt1llTNG FER 101-000-4213-000 S20.010)
1MPRAS T [LUCIAM FEE 22.5-000-443-342 $4,7W.41.
AWC 11' PUif37 IC,PLA% S -'RESI 701-000-25.5-000 S?,34.423
Still=€'tit°Aa CONSTR1.3G`i ON AND PLAN C CLIC K
LESS IM.3 -PAID FEES
$0.00
wro ri%- L n,-Rm, rf v1+.�& s 111Jia NOW
$7,427r87
RECEIPTDATE
.
BY (
DATE FINALED
INSPECTOR
I i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL -APPROVALS
Set Backs
Underground Ducts
Forms & Footings
\ t.
Ducts
Slab Grade
- l6
Return Air
Steel
Combustion Air
Roof Deck
-lcl
Exhaust Fans
O.K. to Wrap
Framing
F.A.U.
Compressor
el
•-
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- g -ICT
Drywall - Int. Lath
- -
Final
---1 Ur/
Final 17vo ov
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
L -
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 — p
Utility Notice (Gas) 1 -70Ct/
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 - v C/U
Utility Notice (Perm) -•• 0. Qv
COMMENTS: