0003-202 (SFD)LICENSED CONTRACTOR DECLARATION
Lhereby 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
697117 f3
Date ` Signature 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:
( ) 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. 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 3TAT9 FUND Policy No. 469-49-0000120
(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 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, [.shall forthwith comply with, those provisions. / t�
Date: ' ^.a/ ..r Applicant"< - [r ".. �'• -`--
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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) - ` _ j r` Date '
`q{ BUILDING -PERMIT PERMIT#
"
{"ti 000x' 2'0'2
DATE` p .LUATION d+ LOT TRACT
�1J'
ii SJ,(K,75 M 9
. , .`53
JOB SITE
APN
ADDRESS 44-730 CALLE eSArI.L omm" 9
60 3 3131-fi83A
OWNER
CONTRACTOR / DESIGNER / ENGINEER
OLT.F'lFiAW "D W 11A)a ASSOC., WC.
OT-JPHAN,C AtTD JA)vW
A88W., INC".
77-900 AVLWUE OF THE S A?T9
77.900 A:VLTtTU OF"I°EM
SUMS
P A1.3.4:i]E.�'.I� ..i CA 92211
PAI.:EES I nWil
CA
92211
.(760)345.2626
C13:Li
5203
USE OF PERMIT
MOLER FANMY 17WFId1:WG
SFIN L17T9 PLAN I PC - PER. IT DOESi NO'P INCLUL?f.13LUC 1C51iALL5 OR
POOL.
a fLACT CONSTRUCTi(Y4 1,736.00 SF
PORCH/PATIO 59.00 Sri
0MZAGIUC:,ARPORT 4%.00 S
-
ESMATED COST OF CNIDNSMUC170Iq
10�E, ;z�i.f3J
CONSTRUCTION FEE 101-000-418.000 $657,00
PLA14 CHZCK FRE 101-000-439-318 $558.24)
MECHANICAL FEE 101-000-421-000 $47.00
ELECTRICAL FRE 101-000-420-000
PLUMBING FM 101.000.419-000 $153,95
�
�' ; ,• ,
STROND MOTION FW - RFSfD 101-000-241-000 $10.48
CRADING FER 101-000-423.000 $20,64
DEVVLOPER IMPACT WE $1,907.00
H
910TS-TOTAL C0NS7.1ZUC`f 10M AND jPT..P,1°J CHI, CIC
$3,481,65
I*. � s PTa P.�m- l &4
$D.00
*
V
I TAL MIMMr _ SySa!7 St"LIF NOW
'A
RECEIPT
DATE
BY t '
,QA E FI LED
INSPECTOR
i'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
{ INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
$
Ducts [
Slab Grade
Return Air [
Steel
Combustion Air i
Roof Deck
Exhaust Fans y
O.K. to Wrap
F.A.U.
Framing
o 1
Compressor
Insulation
161 t 4
Vents [
Fireplace P.L.
Grills I
Fireplace T.O.
Fans 8 Controls [
Party Wall Insulation
Condensate Lines [
Party Wall Firewall
I
Exterior Lath
o E XD
{
Drywall - Int. Lath
[
Final I
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 t
Shower Pans
O.K. for Finish Plaster l
Sewer Lateral
t3 k--sc,
Pool Cover [
Sewer Connection
Encapsulation l
Gas Piping
_
E
Gas Test
[
Appliances
I
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 n
Final
Utility Notice (Perm) p
COMMENTS:
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