0005-209 (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 # Lic. Class Exp. Date
697117 B HIC 108 1 /2C
Date1 !�Signature of Contracto���9���
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 exCltisively 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.
.6441 -nave 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. S•ATEMOD. Policy.No. 467-99-00DO1 0
(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, I shall forthwith comply with those t/prov ions.
Date: I� Applicant /%o?
�'
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)` A � Date �!
-77
BUILDING PERMIT PERMIT#
09
DATE VALUATION LOT,�� TRACT
JOB SITE
ADDRESS"1
APN ,
-OWNER
CONTRACTOR / DESIGNER / EN INEER
t'3T PT—imn AND wTIuwz Assoc, w.
01PROT AN:b WMUMI13 AMC, AW.
77-900 AVMTE OF *ME S'xAUM
77-900 AV•i.i+fl E OF T3.1 1 STAMM
PAL.M.UESEW CA 92211
PALMD]IMT CA. 92211 —
(760)344Sa26i;6s _Lr; 5203..
USE OF PERMIT .
MOLE lj':AitrFL.'i' DWILLM
SFDL LOT 122 PLAN MR/ PERMIT 1-10:'S NOT rNcL.'UDL no= 'f,'mu. OR
Pooi., ALL arum PIt;JiA/jI! a R F.Lii4' 191 REDUCTI(YK `i'O P1,AIR CHROX
ME FOR MULTIPLE ISS1J1=9 OF 4Aie E PLAN ii'1PF.
TRACT CONSTRUCTION 2,292.00 s.F .
PoiZCHIPAT'IO T XO.ftEt j�
GARAOEICAARPORT 12; 04..50
XnWATFD C01Tr 0.F C(3MUC':1`ION .
'138,5M.40
PE MTr FEE $U'N11i"RY '
CONSTRUCTION FRE 101.000.418.000. M00
PLAN CHECK: FEE 101-000-439.31 SIfI2.�6
hZEC1iANICAL FEE 1411-000.421.000 S3d.3i�
ELECTRICAL, ME 10.1=000-420-000
PLUMBrNa FEE 101.000.419-000 $169,30,
S'I'R0NO HJ OTION FEE • R&SID 101-000-241-000 $13.86
ORADT90 FEF 101.000-423.000 00.00 .
I.7IyVELOPEh.Ttt•1PACT Fes;
@+
r
SUB -TCS'' i%< 0 3 11`tCi,TCITOM AND PLAN CH
$3,266,20
LEW PRF�PAID I'M
$0.00
RECEIPT
DATEff> (jt t
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
��
` _
Ducts
Return Air
Steel
Combustion Air
Exhaust Fans
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
L_ (2 C—>�(
�-7���_
t4r
F.A.U.
Compressor
Vents
Grills
Fireplace T.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
vam
Final
Final
- �
POOLS -SPAS
BLOCKWALL
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
Heater Final
Waste Lines
zl--�
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
IN �"
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final ol
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)