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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ghapter 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
686895 H 04/30/2(
Date w 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 & Professionals 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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty, of perjury one of the following declarations:
() I have and will maintain atcertificate 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.
(,)...J-fra"ve 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 SUPERIQR NATIO14A Policy No. WCN78032A.
(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 sha I forthwith comply with those pro 'scions.
Date: !:212c%&.20 Applicant % " �
r--
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) ��-'' -37 Date'' &0
BUILDING PERMIT PERMIT#
DVALUATION .. LOT 00-275 TRACT
7io—d-82M.121.00 33 28490-7
JOB SITE
ADDRESS
APN
79-110 C.mzius,
769kWQ00,3
OWNER
CONTRACTOR / DESIGNER / EN (NEER
sku.:�'TID ETIC>li+i1✓'0
BkiUFWLI 3 k OMM
3400 C11 -FRAL AffEWUltr
I.'1�',d25 :4400 CrR_L AVEN(YE s**TE 325
I1TVMII_)E CA. 92506
R1MZS1XDE CA 92506
(909)662.5352 CB1.6 5386
USE OF PERMIT
LTi#U FAAM,,Y DVfLUL G
SP13- WT 33 PJ. AN 3 PERMIT DUES NOT INCLUDE BLOCK WALLS OR
POOH.
CUuTOM C0113TRUCTION 31102,00 OF
PORCH/PATIO 340.06 :F
C. 1,AffiAGE/C.ARPOP01' (K) 12,485,20
Xi,7dJJYJC>•1ED C09r OF CONSMUC`J ION
, 2.58.127.00
C-ONOTRUC T ION FELE 101-000.41 €-000 81,196,09
PLAN CHWX FEE 101-00", 39-318 $974.07
MECHANICAL FEE 101.000-421-060 SW50
FLFX,*TRICAL. VZE 101--000-4,210-000 $10.81
PLUMI3=ff% 101.000.419.000 $183,00
STRONG MOTION FEE a REBID 101.000-241-000 $35.81
'
GRADING FEE 1.01-000.423-000 X0.00
DEVELOPER iMP.AC'l' FEE $1,907.00
XRT 1N PUBIAC PLACES - R.MIr 701-000.255.000 $145,30
'
`illi- lO`LAL COWIRUII HOW ANIS PLAN C'P3'F%t'.I ,
$4,748.39
LESS P1.X-PA1C1, FU;S
$0.00
'1:OTAL I"IRMT 1' EEVN DUE AOW
S4:746-19
RECEIPT
DATE
4 e
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
/'V�
—_�
���
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Q -,2-0 cU
Exhaust Fans
O.K to Wrap
—
F.A.U.
Framing
Compressor
Insulation
j • lld
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
ZlJ 06
Drywall - Int. Lath
Final O
Final —2 2.Q
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
%7 cc;
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
- U
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.I.
Smoke Detectors
Temp. Use of Power
Final -ly
Utility Notice (Perm) O
COMMENTS:
5 s .
CI1 OF LA QUINTA
cFyoF o� gg014. ik & SAFETY DEPARTMENT
1_1
' I ECTION REQUEST LINE
^� `V 0 777-7153
14
Owner _ jkFFFIEp4_ MES
Contractor =FFIELD HOMES
Permit NuLr 0006-275
POST ON JOB IN' CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS7961Q"lTIU
'SF?,QTL3 PLAT ERMIT DOES NOT
INCLUDE BLOCK WALLS OR POOL
TYPE OF INSPECTION DATE I IN P.
FOUNDATION & SETBACK - -G
FOOTING STEEL
MAIN GROUND SYSTEM
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUNDWORK
:;�7
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT -A/C
ROOF - oQ
BOND BEAM
O.K. TO WRAP Gni
GROUT ❑ 4' ❑ 8'
FRAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
FINALS
ELECTRICAL'
PLUMBING
FINAL GAS TEST.'
HEATING - A/C
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER'
ABOVE APPROVALS•DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING