9808-024 (SFD)* 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. Date
488'.'14 a 12,a1/99
Date p„ a!% 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 a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performancerof the work for which this permit is issued.
. (XI 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.
AATE r, 526353-97
(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 with those provisions.
,Date: g,4,qla iApplicant ; A/ , - -A
_
or/
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) / `.�'>> ��f•, d.aAw'i Date d141j9,p,
PERMIT-#— ' CONTROL# ,
BUILDING PERMITs_o
-t�4
DATE �/ VALUATION M30.154,60 LOT TRACTV.
JOB SITE
� 0 C.2-1..(tNiRA� CG 1iil1J
APN
ADDRESS N43
OWNER .
CONTRACTOR DESIGNER ENGINEER
nfF EX_HAINGE Y\U(
C.
R01 AER. SNi.IilEVf,.R M, 10, & AS3C
78-615 NAPLES DR
796.15 NAPLES DRIVE
LA QWNTA CA 92253
LA QUiNTA CA 92253
(760.)7721-0222 CY-11 # 1958
i
USE OF PERMIT
SiNC'LE FAMILY DW TLLINC
S'FD, PLAN 4B. i.vr 1€17, Pgr�&HT DOES NOT INCLUDE BLOCK WALLS
q•
11 NC.7 03NS l'RU LION 2,200.00 SF
•4 Nor
PORCH/1'AT10 i10,00 SF
GARA..GUICAR1'f 7R'1' 471.ti0
1•i SIU AT ED COS"Ar OF C ONYTT.i><J�' TION
130,154.60
.PERMIT I! EE ilJM MARY
CONSTRVC7.10N FEE 101-000-418-000 $7413.Ot1
PLAN CREC'K FFF 101.-000-439-318 S- 6J8.74
• + ,
NIECHANtCAL FM 101-000-421-000 $60.00
ELEC, fRICAL i'EE f 0I-0t3ti-X20-0ij0 $1,3 f.9't
PLUR4b ING VFY. 101-000-419-000 $140.75
STR.ONO 7vfO'rfl1N f'F:i •-107SR) 101-000-241-000
(ALkI 11NI`G FEE. 101-000-123-000 X20.00
,
1N'FRA%'V11U%T11(E FFE 225-000-443-342
ART IPI kW, IC; PLACES - 0,311, '701 -EO -255-000 $75.35
'
}
SI.1R-TOTAL, COM IRIX7 TION AICD Y1...AN CHEICK
r
$4,706.18
LESS .PrUl-PAH) FEES
TOTAL PEE lalNO FIEZ''S 1DUENIGH''►/
$4,70CJ8
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
11
Y,
;GA's
INSPECTION RECORD
OPERATION
T77;ATE
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
O.K to Wrap
Z, _ jr
F.A.U.
Framing
2 2— Q
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
1111171
Final
Final
BLOCKWALL APPROVA S
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—ej
I A.,
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
i
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
i
Final
Wility Notice (Perm)��/�
COMMENTS: