0210-068 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 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.
�; n�=tt co License #.. AA 1�Lifc,. Class Exp. Date r1JI�,
r- W LO .> 36 0 BWC WO/04
oZ r— Date /'2 r'} 0 Z Signature of Contractor
(Do�-
J U C:) OWNER -BUILDER DECLARATION
WWW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
C'') () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
rn
d< WORKER'S COMPENSATION DECLARATION
p
Z lr I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 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 J Q performance of the work for which this permit is issued.
CD Q U ( ) 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 rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
1-11 Z Carrier STATEtD Policy No. 'A(A046241
cb d ,
J (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
3 Code, I shall forthwith comply with thoseprowslons.
/ Date: L-'-, / 7 • 'ItApplicant / i
!f
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
of the Labor Code, interest and attorney's fees.
is
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 upoi--
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) "" �-` Date
tit"
4�..- ....—..—...a �.
BUILDING PERMIT PERMIT#
i q
DATE //f fJ/ VALUATIONry sy 0 LOT r� TRACTJOB
SITE
ADDRESS 7'Y-1165 ("ONafm co
APN 773-02 a3
OWNER
CONTRACTOR/DESIGNER/ENGINEER i J
31?s7GNA da"OM11, , li�C
SUMDVI CORPOr(A OW
77.5814 C01TN'TRYCLUB 1�`�',M 4WIT,6137
77-645AGO(7.T3`MY CLUB DPXVT, 9MY, 150
MW DESM CA 92211
PALMDEMI"MI' CA 5,12260
(/60)7724Z24 CmW 11'"`7
USE OF PERMIT
0ft,TG .WPA: TDWEI.LDTG
SID • LOT'i PLAN 2. PERMIT DOU NOT INCLUDE BLOCK WAI.:Iay
POOL .11"'A OR DRIVEWAY A,.PHIOAC H, 75% RF.1't.3iiC IOW TO PLAN CHECK
FEE DUZ TO MC31.'I9.lyl 0,!S;1JANC'E OF S"t PLAN TYPE
CJ's?.'t'OM CONSTRUCTION 4480,00 SF
POPICHIPATIO 2:33,00 Sir
CFA'RACI CARPORT 633.00 aP
CO'S OF COMMf
y�y.Ah'TM?ifUD
CONS"kRUOTION ME 101-000-11113-000 %1110.112110
PI,d%rI C1: WK WE 101-000-09-3118 $1107.35
MECTrI"ICAI. N`I?Zr' 101.000.421.000 $100,00
ELECTRICAL F�' 1.01-000-420�000 $03.56
PLUMBING FUR 101 -000-419-000 $143.810
STRONG MOTION 1'TKk? N RfMI.IS 101-000-241-000 $Z0.1R1
ORAWN IFEF 101-000.423-000 SIS100
0lv'ii'V.0P?,R IMPACT ",E $3,40.5.0
AR.T Ih1 PUBLIC PLACED IR>Y...qlr 270-000.445-000 $20,00
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an
%4,093.19
LESS Pi%R4_1A1r,1%14X1S
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RECEIP+--- _!?
DATE `^�
BY' '-
DATE FI ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
ZZ, - 017- _
Ducts
Slab Grade
Return Air
Steel
//- ZZ - 4c,
Combustion Air
Roof Deck
- 3r1
Exhaust Fans
O.K. to Wrap
z _zz
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
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
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) -�
COMMENTS:
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