9908-146 (SFD)LICENSED CONTRACTOR DE ' CLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions rovisions 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 #q y
Lic. Class Exp. Date
101,31/191
�Q/e ignature of Contractor_�*,��
111) N4..
OWNER -BUILDER DECLARATION
I 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).
1, 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.
PI have and will maintain workers' corripensation insurance, as'required by.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensatioK insurance carrier & policy no. are:
Carrier Policy No.
GOLMN EACYLEMS. NWC SQ068-01
(This, section need not b ' e 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 tote workers' compensafion provisions ions of. Section 3700 of the Labor
Code, I f h fh m
Dpt'e': jAk7lplipalynwt!S��
KWarning: Failure to secure Workers' Coppensation 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, clamages'as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the. Director of B6ilding.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, indemnity
& hold harmless the City of La Quinta, its. officers, agents and employees.
2. Any.permit issued as•a result of this application Pecomes null and void if
work is not commenced within 180 days• from date of issuance of such
permit, orcessation 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 e ter upon
the above-mentioned prop for . inspection purposes.'
Vg/ignature (Owner/Age 't) DW6�
ffJ BUILDING PERMIT PERMIT#
DATrYALUATION. $1,16,557.5 19 p LOT TRACT 101,8
78-074 CALIX NORTE
OWNER
CENTURY CROWELL CON4MAINUTE.-S
SA14 BERNARD= CA 92408
USE OF PERMIT
SINGLE FAMILY DWELLING
APN 769-022-039
CONTRACTOR / DESIGNER / ENGINEER
CEMRY CRMVE, L.L. CGIVAIUNY11ES
1,535 SO. I'D" STREF.1"'STE. #100
S40u-4 BERNARDINO CA 9 ,108
1909)381-6007 06119 21210
SPD - LOT 39, PLAN 2R - PFAMYF DOP.S'NOTINCLUDE J3L0CXWALL '
OR POOL, 7.g% REDMMN ON PLA34 CRECK FEE OR MILTHME
'WSMA14CE OF SANIV PLAN TYPE. IJ
CU 110M C01q9.rJ?1UC7r1ni,2,1()7.MSF
P0RCVPAT10
GARAWCARPORT' 494.00. S1.7
Examwrep C(Wf or C0Ns1-"RpCVT1,aN,
PERNITT FE.C.SUMALtRY
CONS114UCTICII4 r�hE
009.00
PLAIN' CHECK FM,
1017000439318
8,181116.2
NIECRX911CAL FEF
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101,*W2414M
SM66
0,11LADINICT FF 6
101 00042-3,-0 00
AKY.EN PUBLIC PLACES -;VJ -000-2554)0
DEVE1.011FAYMPAC7 FE E
SE. B-TCTAL CONSTRWTION AND PL ". CHECK
LESS PRF-PAfD 1;F*,6S W411)
'S DUE NOW
TOTAI, PERIfflT FE L,
RECEIPT DATE DATE F INALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE.-, ;'`_
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
D --
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
.7 J607-0-1—F.A.U.
Framing
Compressor
Insulation—��
i�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines -40
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath—
®�
Final —�
Final
_
—Z ov
POOLS - SPAS
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�,e"A" gir�woaG f ��•-� 6to
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)