9908-140 (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
714i88 l(i3 1/191
/te� Signature of Contractor �` 4
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).
O I am exempt under Section - B&RC. for this reason
Date. Signature of Owner
WORKER'S COMPENSATION DECLARATION"
9
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.
(S), have and will maintain workers' compensation insurance, as required by
S - I - 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:
(This section need not be completed if the permit valuation is for $1.00.00 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 wor ers' compensation provisions"of Section 3700 of the Cabo"r
Code h ort omply v6`Frt os6 provisions:
Date. pplicant
arning: Failure to secure Workers�C,ompensation 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 tfiebirector 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, indemnity
& 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 prope dor. inspection purposes.
tSiature (Owner/Agent) Date I
V
BUILDING PERMIT PERMIT#
DATE
VALUATION -0�;CLOT b TRACTJOB
3 /
SITII
C,A..AXE NORTE
APN 769-022-039
ADDRESS184)62:
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CEN1'lad.Y C12OWML %amlvAmmEs
CE2NT J Y CROWELL CO'KhRiNMES
153-3 5O. T" SMEZ f, S T E. UG0
'1.533 SO. -rf" ,T[R E'T', SIT, g:2{mi
&AN BERNAR DMO - CA 924013
-;SAN BERN.AR DINO 633 9218
(", 13131-uC}.i'7 t 818 2120
USE OF PERMIT
S1Ntil, F FAMILY is WFIL1.fNG
SFD - LOT T 33; PLAN 3R -.FM tvilT DiDiFS 1•iOYINC't i09BLOCK W.43.1.
OR POOL, r5°la I FD7JC'"rK.)14 074 KAX ClMCK.F' E OR MfN)l.,'1'1,1It:15
ZSSURA.NCE OF SAW' PLAN S."5'I?i
CU 11yr(Al CIONSTRVCF(0�i Z3950 8F
P( 3iCH1T�A T'iC3 213.001,1F
0ARA00CA[tPCYRT : 1:00 5E'
OF 4~ownwC,"C"1'ON
PERNU'1. FEE SUMMARY
CONSTRUC T1t"tN Fes; 101-0004M000 $9913 til
AYS..I1 C'kffil.IC.hA 1Q1,f1t�cI:1�31R �2fi3:34
1allfr,CHA.1V CAL �� E 1111•-000-4214000 a99,.%
F1<'FCAEii:.A1»;l'`EF ' .. - '. _101.000••42(MW S.15?.61
'ir�V74VMTNG F Ea 1.01.000 X4'1,9-000 Cif2,5£t
.
STR.OM K01100,1•EE RES JD 101-000-241-4000
(;RADING FEE 1014)GO- 2 i-.000 *20.00
20.0 •0i1�-255-0-00
.ty?+1.3'i RF ,701-000 $22_51y.11y,4
♦?'i" t1.679�71pC:��Pi:�AnnCtzl
y
t�RR f14WR1�' S.MPA :S .t- -, E
:yilii-•tt'(i1"h�L CON`,'�'WCJ"1'1tr AND PLAN CH M
$3,1308.15
Ak
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATICN
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
-->!o�— �!%
Underground Ducts
Ducts
Return Air
Slab Grade i�� �`_
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
—&-r>
F.A.U.
Framing
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
Final
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
_ _ /�
t�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)