0005-172 (SFD)LICENSED CONTRACTOR DECLARATIONt
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
69i117 1 2C
Dated i�1 Signature of Contractorti
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:
() 1 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
perfo mance 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 STATE FUND Policy No. 467.97-0000120
(This section need not be completed if the. permit -valuation is for $100.00 or less).
() I certify that in the performance oftt e 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 Secti n 3700 of the Labor
Code, I s all f rthwith comply with o e p ov Mon
Date: I 2 / 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 purses
Signature (Owner/Agent) _� T Date �' 1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT WisIII TRACT �: ~
04,7$70) -22 2 95 IS
JOB SITE ;
APN
ADDRESS 79,374 CRUX lyA.faA=TO
OWNER
CONTRACTOR/DESIGNER/EN (NEER
011PHANT AND Vfi[,S TAMS fiasoC., luc.
011DRAAP,! t1�2dD-WffJZQ48 A1J90C., INC.
77.900 AV W -TER OF 11-JE3'3'. TFZ
Irl -900 AVEC E, OF THE DT l3iIEF
,PALM DF_S=TCr Qk (_Y2211
PAT M :Dl R0.ZT CA. 92211
•
(7603 r-2626 CST, #' 5203
i
USE OF PERMIT
MGM FA:tvil: X D WFIJ NG
j
SpD.LO't' dd PLAN IB I PERMIT VOES NOT INCLUDY, BWCK K 11A ALL OR
POOL,
TRACT C01M.UCTION . 1,-no,00 S1±
PORCHIPA IO 53,00 SF
-
QA A.CINCARI'47RT (:Ski 0,721,60
F. S77Nit't,:[XD COST OF C OJ! STHUC-110ft
•1.0;4g.757.80 .
PT!:IEtAM 7'E 6=04ARY
-
CONSTRUCTION. FEE M-000-418,006 sm96
PI.A14 CHW K MIE1Q1-•0Cti 319-37$ X353. 4
MECk1AN CJAL FEE 101-000-421m000
t:LECTRICA.L M79 101-000-420-000
PLUMUM10 FRE 101.000-119.000 s0t,73 '
STRONG MOTIOPJ FEE - RESID 101-000-2111-000.
GRADING FEE 101,-000423-000-
0FVF=PLR.IMPACT FEE t �l,40i.OQ,
5U11.TO`1AT, (`'GW8TiZ.UC'1101q'eg1J:A� PLAN �:t�,C;7d
a USS PRE-:PAIDPERS
. $0.00
2001 �TOtAL PKIRD&T_1NPUR NOW
�¢
2
ITLA.+:1
RECEIPT 4
k ..
DATEBYM1
f t
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7p �� �'��
Underground Ducts
Forms & Footings
'j,�
Ducts
Slab Grade
`
Return Air
Steel
Combustion Combustion Air
Roof Deck
��
Exhaust Fans
0. K. to Wrap
Framing
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS
BLOCKW
7
L APPROVALS
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
o
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
_
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
t
Appliances
Final
COMMENTS:
Pinal
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels or
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final ZJ 0
Utility Notice (Perm)