0002-203 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) ot'Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class . Exp. Date
- 407� 07, 31 /2i,
DatelV' 2740 Signature of C gtract'r.
OWNER -BUILDER D CLARATION 'a ,
I hereby affirm under penalty of perjury that I.am exempt from the Contra q or'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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 27044, Business & Professionals
Code).
O 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 fo`r 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.
STATE FUND 046-IIOt!'Y,l33'
(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-l'sfio- td become
subject to the workers' compensation pr"� ovi ons of Section 3700 of the Labor
Code, I s all forthlith compl1pw ih those provisions:' ,
Date: 1, '? /rr 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 agree to comply with all City_and State laws relating to the building
construction, and hereby�aGth representatives of this City to enter upon
the above-mentione�propeity 16r Inspetio. pur Oses.
Signature (Owner/Agent) / r/ DatZ--?/d
Q
r
{ 'BUILDING PERMIT PERMIT#
DATE, V.. TION LOT TRACT .
� , b
C/ �1f . 6Q.2U 515
JOB SITE
APN
ADDRESS 4.9-350 RIOAR1°,NOSO
646-323—W4
OWNER
CONTRACTOR/ DESIGNER 1N�EpsE�cR��y
TtsYq rgp't�t qry.
.�D 1�,3.'w��.T D�.+' vS.'..4VXAv�:F'N
�e/ryeEN
PARKS CO 7e 1�Y.'..�MON
PO DOX 1716
79.295 IRWRC O 1A QX.?IAP.CADR,
LAQi.T1A1TA C. . 92253
LAQUW'1A CA 97,253
(760)771.1941 CkLfe 2996
USE OF PERMIT
31NGLt FA2MtU _Y L1�V?7f LT�dC
SFD- WIT 51 PLAN V1&PEI2MIT DOES NOT MCii.t1171v'.BLOCK. WALLS OR,
POOL, 115%P1LAW CHEC K f>"r.E REDUCTIO14 FOR. WIMPL1? ISSUANCE OF
SAW PLAN TYPL
CUSTOM COM RUCTION %038.000
AARAMCAItPORT (SF) 9,$00.00
__R,VDWA1XD (COST OF CONSMUMIC)N
i'FL2IViTi1.+'� SUABU Y
CONSTFt1IC'1`ION FFX. 1011.000 415-000 $541:00
Pry CHi'rCIC VZE 101-000-439-318 $371.44
1+A1 HAN1CA1 FES. 101,000-421-000 $53.50
1riACT-RU:;AL VER. 101-000-420-000 $129.83
PLUMBING PEE 101.0010-419.0100 $136,00
STRONO MOTION FEE - REWD 101-000-241.000 $16.86
0111 ,JJiN0 PRE 101.0100.423-000 $20,00
DEV'1?L_DPER.IMPACT FEF $1,907.0(1
SUB -TOTAL C0?J 1ZITMtJNAND PLAN CHECK
63,:329.6:3
X'RS0 PRE.-•PAIDF.13:135
$0100
T(YTA.1C, F:1<Ril2IT I'ET-IS DUE 1`7OW
'
n421! k:1
s
RECEIPT
DATE
rBY i
DATE FINALED
INSPECTOR
t�� j
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings
- (Aj
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
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
Utility Notice (Perm) -
COMMENTS: