9905-126 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affA 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
6011684 E3 G� li 4ii
,Qate f ,.`j ignature 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 fSec. 7044. Business & Professionals Code).
( ) 1, 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
Se6on 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.
(This sectio r eetl not tie completed if the permit valuation is fort$10600 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',compensat�o provisions of Section �4of the Labor
Code, I shallrfortKwith comply with,.t se provisions.
D e: r� Applicant
arningFailure 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.
1. 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.
Sjgnature (Owner/Agent) fate—�i
BUILDING PERMIT PERMT#,
DATE VALUATION LOT X90.1.25 TRACT
1)46/10/199 S8.5,70.1 :90 5 ' 23995-4
JOB SITE
APN
ADDRESS
s 71-8 4! PA'R HROOK CUI:f k T
604-040-4121
OWNER — -• CONTRACTOR / DESIGNER / ENGINEER
fNCO HOMES CORP. INICO HOMES CORP.
1282 W. A:ftltOW 14WY 118-2 VIV—ARROW HWY
UPLAND CA 91.785 UPLAND CA 91785
(0109)981-8989 C:BL# 3318
USE OF PERMIT
IM 4366R"1161
b. -NI.f
.SF 1) -,PLAN iA1d, f,C)1 � + t?L•Tt�93'f f�(ii s'1aU'r T1vC1'i�DI _.AZCU>v3: �VAL:t S
OR POC11..
'f'12ACr CONSTRUCTION ION 1,411.00 S£'
PORCHMAT IO 70.00 3F
GA:1bWR'C:ARINJRT 41.6.00 SF
1?,S'=A 11"VI COST OF COINST1t.U1v.'�'10N
PERMIT EEE SUMMARY
CON:STRUCTION.FEE 101-000-418-000 $576:50
PLAN CHKX Fa 101-000-439-•3:18 $ 48?.50
MECHANICAL FEE 10.1-000421-000 547.00
FLECTR1CAI.FEE 101-001c 4`x0-000 5.106,21
1PLM4B NCr FEE 101.-000.419.000 $14811)
S1R0270 M(YriON rh'E - RFS1D 101.000-241-000
GRAOINC) F'EE 101-000-423-000 $20.00
lNFRAS`f°Rt.IC Tthb, FEE 2`25-000-W3-342 S i,907. 33
,$'3,301.13
XAL CONS1'RfXHO:NAND PLAIN CHECK.
LESS .('11?-flA11' 1+LI;S
$0.00
JUN 01.9.9.9
TOT. -M, Pl.I RIV.I1.T FE.E, S DUE OW
$3,301.13
Y 0 F L A QJi d,
a -a lit
RECEIPT -
DATE
BY t f
L\
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
— 5`9 45114.
F.A.U.
Framing
c —
Compressor
Insulation
-y —
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-- v
Final
Final 2 -ZZ I"
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: