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LICENSED CONTRACTOR DECLARATION
�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. - Exp. Date
'101039 13 1nV9
,pate ,=�Q Signature of Contractor >rr'^' �
OWNER -BUILDER DECLARATION/
I hereby affirm under penalty of perjury that I amlexempt 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 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 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.
S . A i E F u,4.t) 035-97.40)11236
(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 shall forthwith comply wi thos_e-pr-ovisions
Applicanf'� - _ :� /A
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 I;
application. . r,
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 pu posey_ 1
Date��isJ
vSlgnature (Owner/Agent) ,Tf
BUILDING PERMIT PERMIT# f CONTROL#.
�xtwa�s
DATE VALUATION LOT �t� �. TRACT �� 1(9 O
��
17/
JOB SIT '' .y
ADDRESS 57-`58 7 COLONlid
APN
761480-026
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MCCOh;iC-SEQUOP 1.1,.0 .
TRANS 1. EST HOUSIM3INC
750 A S'1' STE 3110
78-401 P HIGWAV 1,11'
.SAN DIEGO CA. 92101.
LA QU1NTA CA 92253
(7�0} 171-3303 CBL# 4972
USE OF PERMIT
S1� U
SFD - PH t. LOT 41. FLAN 3L'R. PFAMIT DOES NOT INCIA0E BLOCK
WAIL S OR POOL. PLAN CHECK M REDUCED BY 75° o FOR, NAXTIPLE
ISSUANCE OF SANX PIAN TI'F'F.
cusi'ma CUNSTRucr[ON 3.013.00 SF
1✓ORCHIPATiO 325.00 ;tF
CIA AGE/CARPORT 600.00 4I:'
I):STI.MATED COST OF CON81R.UL"'ION
251J,;9 ,;1
, RAHT FEE SUMMARY
CONSTRUCTION FEE '101-000.419-000 $1,163.00
PLAN CHECK *W -H 1a1-000439-318 $239.5+
MECHANICAL FEE 101-000421-000 $124.00
HLEC!'.h`1CAL F, 101-000-420-000 $1?4.96
PLUMBING FFC. 101.000-419-000 $1.91511
9TRONQ 1%40TiON FEE - lZEMD 101-000-241-000 523.08
r. PIADiNGFEE 101-000-423-000 $20.00
tNJ`RAS"1`ttU 1`URF:FENT 225•-000-443,-342 55,545,64
AJRX IN PU 3LIC.E LA.( +IS - RESEi; f�.1-000-25`s-OtiO $37699
f
4 '
S0ja4C7j'AL C "'UCIION AND PL -1N CHECK
�",1'+►h,ti7
1..1 SS PRE -PAID F1;EN
i1iJ.1if1
JUL 190 'TOTAL PERMIT FE VIS DUE jti'OW
S7,8".67
� 7 '
RECEIPT
DATE
BYE "'
DATE FINALED
INSPECTOR
a
1.
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
.. Q -
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
_ _
Compressor
Insulation
p _
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 W17
B.LOCKWALL 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
k _ Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_
/�/�
Pool Cover
Sewer Connection
/
( :j /' �Y .�
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.I.
Smoke Detectors
Temp. Use of Power
t.
Final
Utility Notice (Perm)
COMMENTS: