0301-117 (SATT)1 • ; 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
584656 B 01/:91/2(
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 C;OH CS& N,1D1jS, Policy No. WC92873
(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,l•shall forthwith compl�with'those provisions-.`
-itea/'%/i f0 APPlicanti /. ,` / / i.�lV *rc
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer io criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of4he 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 upori 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 cessatidn•.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.
/ f//X, K 1
,Signature (Owner/Agent) Date,
BUILDING PERMIT PERMIT#
1-117
DATE VALUATION LOT TRACT
$293.52710 299C 9
JOB SITE
ADDRESS E) fiA1'3 A,tO R0V_4 PL"' A_
APN
770-020-00.1
OWNER
CONTRACTOR / DESIGNER / EN INFER
C. WAS LAA ROSM Ll C°
JFn__1Z3- Y C. S°l.`IC NF, DBA SL1'War liSiJi:(: DE -12I
P.U. BOX 1503
4700 VOKKAF(1V AN AVrs#100
1J., QLT1A1'1;'A CA 92253
N 'WP01ZT DFA`.fl CA 92,660
(949)450x:.911. CBL4$
USE OF PERMIT
MO1X FAMILY KrfAC=1 t
sulu'I1 o#I I Tyve S, 5472 S.F. f3•' MITS. PERMIT DD S iJtr t' .'
114011UDIZ. IILOCK WA115 OR Pool's
PORC14/PAT'IO N0109 3F
CONTRACT AMOUNT NT B8%,3 35.20 LS
X61WW17.D COSH' Off' CONSTRUCT1011
293,527:, 0-
CONSTRUCTION PER, 101.000-415-000 $1,318,30
o
N'LAN CHECK FEE 101.000.439-315 $1.284.69
MECHANICAL FEE 101-000-421-000 $263,00
21AWTPdCAL FEE 101-000-420.000 $31102
I'Li91±;9DINO FLOE 101-000-419.000 $30-00
STRt.OMQ MOTION IW • RE SID 101.000-241-000 9134,35
DI 91,0€ ER IMPACT ME Rib,OUB,�9
ART IN FU00C PLACES - RFFIE 2'704=4+45,000 �t333.137
RM-TOTAI, C;O:t+lWITW(, 0.1~4,MM PLAW CI; CTC.
51.9,899.38
USS PPX--PAID FM
$0.00
apFEES' 'TOTAL, POW, IT I�11'9 NOW
pUG 11 2��3
OF LA
Cin
REC
DATE
BY +
D E �I jLE
INSPECTOR
O
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
O 3
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
// -Zo • O 3 Z;r
Exhaust Fans ,
O.K to Wrap
. 2, . 0 3 -r-
F.A.U.
Framing
q . D 3 S -T
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
F
m • Qo3
Final
Final _
BLOCK -WALL 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
8. IS, 0!5 y
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure.
-Shower Pans
OX.for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/O •3t.0 1 4-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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