9908-135 (SFD)LICENSED CONTRACTOR DECLARATION
1 -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.
Licen e # Lic. Class Exp. Date
7141 FS f3 10/31/19.1
%G�
ate � � Signature of Contractor
OWNER -BUILDER DECLA ON
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).
( ). 1, 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.
()if 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 Policy No.
GOLI EfJ EAGLE INS: N C SU06"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 shallnot employ any person in any manner so as to become Subject to the
Wor1%rs' compensation laws of California, and agree that if I should become
Vos lect to t 'e.wor'ers' compensation provisions of Section 3700 of,the Labor
de, dh it�y6mply wiht,, pr ,visions.: �.
Date: ! Applicant
Warning: Failure to, secure Workers' Co ensation 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 mbove mentioned pro{. q for inspection purposes.
t ignature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
9.�s
01•
DATE VALUATION'bQl�}t 7,80 LOT TRACT '20158cis8
ellw11lr
ADDRESS 78-052, CALLF, NMI,'
APN i�9-0�2• (de$1 r
I
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY Cl0.11ATILL 4.OMtVIiJ.NI TS
CENMARY hJ.f.S..4 CRILOWYLL C01111M INIMES
i'_�35 ,SO. "U"S'1'1�F� �, MR 9200
1X35 SO. "13" STR:E r', SIT ff20d
SAN BE,101ARDIN10 CA. 9240
5.:iN B1~MARY31NO CA 92903
(909)3131.6131'/' CBL#t 2120
USE OF PERMIT
SINGLE fM41IA .MVEL1JNG
9FD - LOT 28; Pl,AY312 - PERIMIT DOES "NOT t.13.C11.UDE DLOCK IWI(0;
m POOL, .
CUSTOM; f'ONS".MLtCCION MM SF
T.,
Pt'3i�t��`,:'�//3/T� XTdAO 213:00 SI?
�y ♦
5f4.00 SF
EY1Ci:NATED—Co1w OF CONSIR3.tt:T101W
CONSTRUCTION FET. 103-d)Gf1-418-(iatl
PLAIN c:iiECi4. F 101 -000-439-118 $813.:10
'1�►' C'i�dAP�i'tC:AL'F 10.1.--LitM-421-ft01}• $�1R.50
ELG.CTRICAL:FPE. ':).01-10W-420,000 S 1 S2;6I
PI:.t:`A1BfKG FW. tEJ1*-000419-000 $162.50
s,rRobro Zv ono.N FF:8 RFsED 101-00-241-000 $20105
GRADING M 1OJ403t4L -ON
A.RT M PUBLIC PLACES - M%.' ' 701.^€3I}D-155-WO $251.14
MVELOV R,tMOA.C:"1`:Fask?
SUR -1'1'4 L CONSTRUCTION ANT) PLAN CHECK
S4,413.20
,ESS PRE -RAMP :S
1i.t7t3
ToTm, Prma rr 1 FFs u'u, Now
54,418,20
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
4
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
Exhaust Fans
O.K. to Wrap
Z8—oc
6'
F.A.U.
Framing
f ®d
_._
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
—l!/.�t>
6Ll�
Drywall - Int. Lath
37 va
_
Final
_
o !9
—
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 Lin es
�, `
�}
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
/���
//
Pool Cover
Sewer Connection
1�
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
�Qok co�u.•rS
6� � /,f��
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
01
Main Service
Sub Panels
Exterior -Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
/
Final
— ve
Utility Notice (Perm)