0006-182 (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
711188 I3�. _.,��`10/31/2(
/ateSignature of Contractord�7
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
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 ti Policy No.
001,69Nt&A.t11..E 103.NWG•344068-02
(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 provision-
(/eate:
Applicant—
Warning:
pplicant 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.
ignature (Owner/Agent) 5 /1- n -✓ Date il" A�F, '
&J&'(9(J BUILDING PERMIT PERMIT"
DATE VALUATION LOT 00()6-182' TRACT
5150,449.70 13 203 58
JOB SITE
APN
ADDRESS i 7.� C S
769 -037
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CFId`t URY CROS c(.)t44tM'T.r 0
CEMU RY CROVIML C Ulb1'MtiNT!'t£8
02.00
1535,U0, xv mr:ItF x, am #200
SAN B'IRN'ARDWO CA, 92408
8PX:BERWARDWO CA 92409
(909);11316007 cavil 2120
USE OF PERMIT
MQUES, k.A1uII1,`1! DVM�G
S;}D• LOT 13 PLAN IBR- PERMIT DOES NOT INCLUDE BLOCKWALLS Cita
POOL, 75% PLAN CHECK FEE REDUCTION FOR ISSUANCE OF S,AW
PLAN TYPE
CUSTOM CON3TRUC'TION SP
GARACIFUCARPORT (SP) 9,906.00
Z w
ES I;III>IA:LT.1D COS" `l' OF CA.ia'yrRuclfON
PER Ir PKK 8'liMl'vTA&'Y
CONSTRUCTION FEE 141-000-418-000 1013100
� �_3fk
PLAN CHECK FEE 101-000-439-918 $164.92
§' I K-'
MECHANICAL FEE 101-000-421.000 $33.3®.
� s
ELECTRICAL FER, 101-000-420-000
P1. hiB1140 MZ: 101.0000419.000 .. SIMS
.24
STRONC9 MOTION ?EE • P -MID 101-000-741-000
L' RADINO FEE 101.000.423.000 4 Si?,00
DLfV'U,OP9R IMPACT FET$ $1,90woo
SCJ;1349fAL ('.0?;SMT7G`T' ON AND 1?'Z.AN CIiF+=
$3,222.42
LW19 PRT11-P.AJD FEES
$0,00
WEAL Pt. -IMM ITES DUE NOW
V4,222AZ
RECEIPT
DATE
BYr ' i
DATE FINALED
INSPECTOR
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
-p
Exhaust Fans
O.K. to Wrap
—/ —p
F.A.U.
Framing
—2Z _ &2 B
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
/ 07
Final 6V
BLOCKWALL APPROVALS
Final
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 APP OVALS
�j
Gas Test
Electric Final
Waste Lines
j�J1,
Heater Final
Water Piping
/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
P,MMENTS:
vis 4_10-.t;, E f
.1 5'
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
Utility Notice (Perm)
MAY -2572001 15!59 WESTERN INSULATION
909 686 8766 P,14i27 't
u INCe
.
4111 LB[hm Gt=f,'R1Y60`2
686476o lei (909)%686.8786 ,
"fit
THIS 1S TO CERTIFY THAT INSULATION .HAS;=