0210-069 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O Z) cn License # Lic. Class Exp. Date
t` O`n 333670 :13 hip X0104
oZ r- Date - -1 � - — Signature of Contractor
O 1, _ �.
r-
i.—
C� OWNER -BUILDER DECLARATION
W WW r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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
N Date Signature of Owner
ON
G7
O_ Q WORKER'S COMPENSATION DECLARATION
O cc I hereby affirm under penalty of perjury one of the following declarations:
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the.Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q L) ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
d Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier BTA11; INIIND Policy No. 1616462.01
cb —1
g (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 provisions.
s, Date/ 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
Y 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 & eachperson 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. U
f
Signature (Owner/Agent)Date
BUILDING PERMIT PERMIT#
DATE 1 ^ VALUATION $ '
6,1)4S.2() LOT 8 TRACT 10125-2JOB
SITE
ADDRESS X77- 775 Cf_NN A t'O�I r
APN 773-0122-M33
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SEDONA:fSO;i.t'�FUS, INC!!
9015LO 40?PfRJ7C14
77•v64 COWtJi37PRW SUM,rxd
7/-44:5AC0gT9rRxCIArD-1YE WITE 3 50
PALM DRSSICA 9221;
PAT-M.MSWi (.A 92 260
('760)772.97,?' C331A1131
USE OF PERMIT
13NO LVIFly"U..T, 1a1�7i
Sf) n;ZIT IS PLAN 1. f'1p..RUIT 37 93'NO 11dCLL I)E. hi.00K'6xarALLS,
14004 SPA OR LaztIVFWAY APPiti>.9aCH. 7,5% iiROUCT1ON TO d''C{AN &wHF'OK
"It DUE TO MUL:TIPLP, ISSTJKNCE 0FSAW, PLAN 'a YAtY ,
CUSTOM CONSTRUCTION 2,236.00 SP
PORCH/PA`I';'O 186.00 SIV
0Ai$#iOFICA.RPORT 52510D 0+p
Efflim1to.) Co'..�' OT, CC?RMIR`OC111off
x130;, £S C1
COIN l'i$UCTIOx3 T;12 101-000-43.8- 000 $94440
ro,1 Alit CHFXIFI. FRY, 101-000439-M $192.23
\+1I;+3HMOCALF81 fol-CAOO471.000 01100
fid fi?X 7'11iC?t'1. VISE 101-000-420-000 $122,26
PimUMBIN'a FEE 101.000.419-000 $162,50
STRONG MOTION FES • C21..3I'O 101-00-0-M-000 $18.69
GRAMNO IPI;I: 1 Oi l -000.1123.00 0 $15,00
DZVELOPFR IMPACT PEE $2,4dIS.fW
OWSMUCTIOM AND PLAN
MUD
Ci. 2s :ilC:ii1"Ta
RECEIPT
DATE f f 5
BY
DATE FINALE
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
Z —By
Combustion Air
Roof Deck
0 L
Exhaust Fans
O.K.to Wrap
/ — / —
F.A.U.
Framing
Compressor
Insulation
C— Z —
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
4�1
Exterior Lath
Drywall - Int. Lath
_
Final Je—
Final —3
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
2
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
/
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/ / —
Encapsulation
Gas Piping
_
Gas Test
Appliances
_
Final
FinalUtility 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)
COMMENTS: