9905-118 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby;raffirm under penalty of perjury that I am licensed under provisions of
Zhapter 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
� '91684 f3 rf
�s;teEp
/) 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 & Profgssionals 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
0,
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
Seefidn 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 I Policy No.
(This section 661 foltI bWcompleted if the permit valuation idiot $1 AQ0 or less).
( ) 'I certify that in the performance of the work for which this permit is issued,
I shall not employ.lany 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 th'se provisions.) f
/De : / Applicant arning: 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.
1�
S4gnature (Owner/Agent) J ����n J "� ..,Date•
BUILDING PERMIT FERMT#
TRACT
DATE VALUATION LOT TRACT
_1
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► ,�� � Air, � �n��S_.�
JOB SITE
APN
ADDRESS -------
-------- --. r
'PAwKwRom to
,t R,
OWNER —v_- _ -
CONTRACTOR / DESIGNER / ENGINEER
MCO HOiLMES CORD.
INCO HOMES CO&P.
1282 W. ARROXV 1AVY
1282'W.. ARROW RWY
,
UPLAND CA 91.785
'UPLAND CA 91'785
'-
(909)"I.8989 c:ALff 3318
USE OF PERMIT
3F:D - PLAN 2AR-3, LOT ►, - P1 Rr%,fiT DOES NOT INCLUDE BLOCK
WALLS CR POOL.
T12ACT CONSTRUCTION I,St�li.00 SF
PORCkIPATIO 81.00 Sr
GARAGE/CARPORT 599.00 Sr.
GS' IIMA'1T13 COS!` OF CONSTRUC .1.OIY
99.851,511
PERN111T FEE Si11NINIARY
CONSTRUCTIONFEC 101-000418-000 $630,54
PLAN CHECK FEE 101-OW439-318 1530.111
'Vi'EG'RMICAL F gE 1.01-000-441 MO 1;53.50
:
ELECTRICAL :FT -6 101-000-420-000 $ 1.15.29
PLU111BIN0'F'EE 101-000419-000 $.143.00
6TRO140IVIOT1014 FEE - 101.00024.1-000 59:70
GRAOINO T -FE 101-000-423-000 $'20.00
1NFRASTRUCTUR:E FEE 225-000443-342 Sn.17?.42
SU&T0TAL CONS'FRUC TION AND PLAN CHECK
$3,684.+1
LESS PRE -I -AM FEPS
$0,01;
T 'fAL VEIR IT FEES .SUE NOW
$3,684.51
All
RECEIPT
DATE
BY •' I
DATE FINALED
INSPECTOR
INSPECTION -RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings p919
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck 2 _g
Exhaust Fans
O.K to Wrap
F.A.U.
Framing /°p — B
Compressor
Insulation /0 —/Z—g GOO
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 17,• `a -Z h d
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 LateralPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wining 0-Y7 A 41
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final i2 12 -�jy
Utility Notice (Perm)
COMMENTS: