9908-138 (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
taD to Signature of Contractor
OWNER -BUILDER DEC A 'ATION
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&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.
( .1 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 EAGLE IIRS, r NWC 544068-01
(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 1 should become
su,'ject to t e workers' compensation provisions of Section 3.700 of the Labor
Gode, f r h th mply wi •th s lovisions.
✓Date: pplicant
Warning: Failure to secure Workers' mpensation 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 pro a fo'inspection purposes.
VS nature (Owner/Agent) Date
BUILDING PERMIT PERMIT 990S-138
/
DATE �Q9 1 VALUATION 1).52,%3,40 LOT .31 TRACT
SITE'JOB
ADDRESS. %8-0.158 CALLS NORTE.
APN 76IW21-0391
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CEN'MY Y CR.OWELL Cf3MW!ti1'!' ES
CENTURY CROWELL COMlblCJN1T ES
1515 Sty.'D' ,51REE T, STR r No
.1535 SO. !- Y1 SU1�:1:��: 5��. f€Mo
SAN BERNIU1M2NO Chi. SSY2408
SAN BEfi NARnINO CA 92408
�5�1i9j331-FattlJi tw°BLfY ?1219
USE OF PERMIT
SfNGLE RKNArL'Y DDE -1.1 NG
SFD -,- L0T 3l, PLAN NOT iNCU"K Da.00 WALL
OR POOL,
CUSTOM CONSTRUC ION 1'Sma.00 SF
PORC 4i"PATIO 1 .(k1 I
14
CONSIr UCTION FEE 401-0904M 000 9�2Ri-Oi3
PLAN CRECK FP -E 101.000-439»318 S05#2
MF1_7HAN1CXL FEV, (t}1-{9CrdJ-�ii'.1-i1t3i! $GG. �
k LI?C'I`fit CAl� "N fj�. $:03.-2100 4.iO4ft $130.81
Pi..'MMINGM $143,25 .
STRO NO rMA:TION FEE - PE310 101-M-241-000 $15.30
GRA DING FE6 101-000 42 40) 32D
ART 1N :3YVBL1C PLACES - NREM):; 01-l'G(i`.'rr:23,-i= S1'32A-1
DWELOPER ►:-rnA1r, r FLS; . 1,W7_00.
SUR-'1�iS'.�' L COiYS:C1i{.k"110N AND PLAN CIMCK
Lr!,SS ;i?i : P.R1G :i'ERS
3',0.00
JJ
RECEIPT
DATE
BY ' -
DATE FINALED
INSPECTOR
Co
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
KP — 9 6 !, j
Ducts
Slab Grade
j jam— �_� ®�
Return Air
Steel
Combustion Air
Roof Deck
���a ey- D
Exhaust Fans
Rn�X to Wrap —2
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
C?a
Final
Final / — _
BLOCKWALL APPROVALS
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
Water Piping
_
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Slower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Finalia>dCci-
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 O''a
Utility Notice (Perm)
COMMENTS:
Q,c�OlC Go%s. S �o k S- Seca