9908-147 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm_ under penalty of perjury that I am licensed under pirovisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profession Code, and my License is in.full force and effect.
Liqense-# Lic. Class Exp. Date
ate signature of Contractor N
OWNER -BUILDER DECLARATION'
.1 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 liceriged
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I am exempt under Section B&P.C. for this reason
Dat` Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjLiry one of the following declarations'
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
p ance of the work for which this permit is issued.
VKI 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.
GOLDEN EAWI INS. NWC 5440a -IJ I
(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 th6.
workers' compensation laws of California, and agree that if I should become
subject tot � wor2�rs�'compensatlion rovisions of Section 3700 of the Labor
0 /-P
de ply VaCwWrokisions.
ts-,Wlftj�� ra lirnnt
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
th7e. ovd-mentioned pilo�pe� or �inspectionn purposes.
%,Signature (Owner/Agent)' Datea4
#
BUILDING PERMIT PERMIT
DATE. LOT
VALUATION 40 TRACT y()158.
JOB SITEAPN
ADDRESS. 78-W6CALLENOW C.. 1 6.9-022-039
OWNER
CIENTITLIKY CROUTELL. CONIMUN11IMS
SAN BERNARD= CA (92,408
USE OF PERMIT
SIN
. I CILE FAMILY DWELUNG
CONTRACTOR/DESIGNER/ENGINEER
CEVIURY
.1535 So. "D!,s-rREL-,r,'STE. 4 ma
SAN BE"LARDINO CA 0408
CBL# '2120
SFE),; LOT 110, PLAN 3R -PROATT DOES. NOT NCLUID9.BLOC IOVALL
OR POOL,
C % 39�
OMM COSI
NMIX-InOm $110 SIF
pokmPIVRO IJI3.00 SIF
laARAO&MRPORT 50.00 W
ESTIMATED COST OF CONSTRUCTION -
PERART FEE SUNMM
CONSTRUCT10N T-7133
101-000-41840tZii
$993.01)
PLAN CHECKFEE
14-000-4-39-319
$80.40
MECHANICAL FM
PLIAABINQ nEP,
N162.50
I 517RONG MOTFOAL FES - REM
.1011-000-241-000
S20-05
ME
10 1 -00"23,-000
5-20.06
K T7V]BLW, PLACE' 3 - RF-MC701 -000-23�WK)
ART L
I)EVELOPCR Vk1PXCT FIA,
'L a�.s pful-mlo vas
TOTALTEItM' FEMME NOW 54,418.26
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
e
BUILDING
APPROVALS
MECHANICAL APPROVALS
S ,, acks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/Q
Return Air
Steel
Combustion Air
Roof DeckfZ�
Exhaust Fans
O.K. to Wrap
% _ �a—�r'6�—
F.A.U.
Framing
1 �� y_arp .�
_
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 — — 2
Final
df —Z
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Hacks
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
�= 6 �—
Heater Finat
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
Appliances
Final
COMMENTS:
Final
1313 O le 614
"��-� o A— S' g C
Utility Notice (Gas)
/r�—�^�e o�. t
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)