9607-123 (SFD)LICENSED CONTRACTOR DECLARATION
1:•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
J89-234 13
S
�/ate Signature of Contractorr�Qy
w
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 prOpertjl, aM ezcluslvely 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 3780 of the -L Code, for the performance of the,work for which this
a r�t.1 he -L Yi ozo-'..�1y.r
permit is issue . My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(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,J s` al forthwith comply with those provisions. t
Date:
(P -TA Applicant- i (C--
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
,,he above-mentioned property for inspection purposes. ~�� ��;
Signature (Owe n Agent) Iry �.-+�t'\J ��-{ S�''�y`-'MDate-/
0
BUILDING PERMIT
PERMIT# CONTROL#
��.�t3 3 799
DATE VALUATION 51i•99559.80 LOT
TRACT
JOB SITE 7!x-005 C)CO i ILLU DRIVE
APN 604-.-26-4-0
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1'.WER SNEILEN'llb.&GER & ASSOC;
41465 BOARDWALK; SUU8 212
4.1,465 SCIAM WAL ,, SWA-- 212
PAI..it9 UP.SCRT CA 102
1%ALAI ()FSI -ICF CA 9221 t
1.619)777-17(gi
049.1777.7766 1858
USE OF PERMIT
S1N60" l�A.filI.L1' I.iV101s1.1.11V�i
Sf� t�t $lt 1.tJT !6S
ttAl2A.�#if<,11�i/'�);'f' SctY1.UE1 31'
'
oi,STINIM ED COSTOF CONSTRUtrt' ON
15.919.59.80
I".XRN'i'IT 8+F, SSIJMMAKV
K AN C, MtF�.:,K FT. i 101-000-439-31$
S7f)1i,90
t`OiV'u'iRUC 11ON FEE 101-000418-000
$849.30
MT-01AIv1CAL 170- 101.000421-0110
140,66
K.EiMICAL FEF 10.1-000-420.4ft
$136,01
P.1.trN4R,(N0 FGF 101-000-419-000
$190.40
S 1 ONG MOTION FEV- RESIU 101117f.0 -241 -OW -241-OW
$16.00
GRAGANC( M11' 101-0)-423-000
520.00
1M RASTRCiG"I' )RE 1703 225.0(91.44.1-342
ART IN KYBLTC PLAC;`f 8 - RESIP, 701 -1910-215-000
S.119.91
Yx3 j 'AL C: _ NS! .: fCr ON AND PLAN CHEM
$5,749.41
S.ESS PRE -PAID ITES
$0.00
' JUL 31 AI(IRI I'Z�hlfT FEMS
i
KIP, NOW
S5,749.41 ..
. f
.
RECEIPT
DATE
BY
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
OX to Wrap
F.A.U.
Framing G
Compressor
Insulation 001.01,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath '
Final
Final
BLOCKWALL A PROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
0. K. for Finish Plaster.
Sewer Lateral loo,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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)
COMMENTS: