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LICENSED-CONTRWC-TOR- I)Edi:�RATION
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
0)"1 0120(
Al
C
Date 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:
( ) 1, 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
( ) 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 I have and will maintain workers' compensati ' on 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 Policy No.
t
(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 Sect , ion 3700 of the Labor
Code, I shall forthwith comply with th
Date: Applicant
Warning: Failure to secure Workers' 0,prnplMnsatioln"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 inspe*c on -purposes..
Signature (Ownier/Agent)-_-__ I Date 1/1,
PERMIT#
BUILDING PERMIT
99011-049
DATE VALUATION ,7.1 2�.6j) LOT TRACT r
.52319 4
JOB SITE
ADDRESS 79-040 CTFRUS
APN
769-670-0.18
OWNER
CONTRACTOR / DESIGNER ENGINEER
V t) r, F? C. 1. r; I -L� f_-1 () �%,i. E S.
1#11L. A. .4 ,
S"HIEFFTELD I
i HOMES
, CE, K, k�\L M.T.-T.
W V _UE .5rE 523
1:0 CIL* NTRA, AV EWE STE 312 5
CA Y2_`106
IUVERS11101i CA 925M
USE OF PERMIT
GLE FAMILY DWELONG
3FD - LOT 4 PLAN2"Alk PERMT. WES �.KOTWCLUDF,� P00L OR BLOM
WAL1,
01011IT01M CONSTRUMIGN Z886.00 15111
PORClYPAMY 1424.00 9-1
GARAQWCARPOWIr .540.00 SF
EST1114.1.1401PED COST 14-1111, ur"rnN
,wig Vt,& a
OC'WIT FEE SUMMARY
a)N-S'(T<VCT ION FEE 101-000418-000 io
PLAN CHFCK F FE M -W-439-318 $921,48
1%1l'.EC1W4I.CA(. ME 101-000-4211-000 $85.50
P_'LWTHJCAL FEE 10 1 -000-420-01N) $18831
PLUMBM0 FIX 101-000-419-000 S18t.75
STRONONIX-Y110K FEE - 11 fi-ISID 101-(W-241-000 S23.911
0RA01 NO r- IX t0.1-000-42-3-000 520100
NFRASTITUCTURE FIM 22.5-0004,33-342. V.5.29638
ART W PUBLK; PLACES -R-E&M, 701 -ON-2-55-000
"AR M
LESS PKE,4 FE S
4750,0`
si,446.37
d30 T)N'' A
G3A13,.JZ-2_.. Y
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
%6ATE
T INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
'?
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
Framing
F.A..
Compressor
Insulation
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 APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I I
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
4hower Pans
OX for Finish Plaster
ewer Lateral
--Z761
Pool Cover
lewer Connection
Z) OA
Encapsulation
Gas Piping
Gas Test
Appliances
-Final----
Final
Utility Notice (Gas) /�4 - t� 67 El AAA -
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)
COMMENTS:
A