0109-252 (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
7
Date ('' �� Signature of Contract"--,
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).
( ) 1, 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
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.
( ) 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 ts4wI�8+6 Emx ms. ' Policy No. 1+rwc_%406"3.
(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.
Date: , r t f._ Applicant #Y�':
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.
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 uponk
the above-mentioned property for inspection purposes.
1'
Signature (Owner/Agent)";, b t_. it
A. Date"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.tf>. - Y TRACT
Nr�
$10$1031070M241 ar r tv�
-31
* . / ,.
JOB SITE
APN q?
ADDRESS i11. �'S ^` �`r 1?. i
C+ X4) 7'.n�•`(W
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C:'1rN'l.OIZZY CROWELL COMMW` LES
C:'.1r'�3"1�8:dRY CROW C:OWAT)AM' WS'
1535 i50, `1Y i„':�: 4711', 3TP 02,00
1535 3'0, T" STRM-7, ME, $✓1200
SA MPNARDINO CA 9?.s1£}t3
SAN BMW:T .f O CA 924-08
(909)381.60f3; (71AI R 2120
i
USE OF PERMIT
t..LiT 2,1?f A..'N RA FY. P1+,.ItiMI t E)OF's NOT INdE°1.VD4 BLOCK
WA:LYA P001APA.OR d:;l{1VWA„Y.14WRt.'ACH.
'TT4M.""1° COMMUC"I' UN 1,72,5.00 OF
PORi:1ifA?ATIO 01.00 SY
iC1l1.111wMMIARPO'RT A13.0dt OF
Jpe�fp7..T.6t"IED COSTOY aoOF,9MiJ vri4Jlt *..5.7
- A.c� sa�•Y 117.�i�
y,, �y'jp� �+ ,Ay, •��y���,q;
2: �iY�LLP.7.�aeM ,�4�+AL Ci49AiC9,7.Vp1GM'R 74
FAB DEPOSIT 101.000.439-.318
ViON M?th.`'3IMI PES 101140 0-419-000 �i33.L�0
PLAN CHUM FRE 101.0 0439.,318 $M4.0
MV,CT;:H:1!3iCAL EPEE 1.01-000-421-000 $0.00
CL1;.CTRI(A1.. VER 101-000-420-000 $1171-24
1"LGl?>EHU40MIIX, ),01-000-419-000 $110190
13 i 11 MOTION FEE - =31D 101-000.,241-0100 $10.31 _
-
(1R.,M,fZ'0 FE1111 101-000-423.000 $20,00
MA}.Ld PER IMPACT FFA $1,907104
141M --f OTAL 0,011';�'.i;R U AND 1;11•..x,9 01
U -2243Y PRE -PAW FEES
-$f750.00
GE a Y OF LA G?L"TA
FIN %tt�Cl' D�PT-
RECEIPT
DATE
BYj
DAT ALED
INSPECTOR
'INSPECTIOO N RECORD
OPERATMIN
IC
INSPECTOR
OPERATO !
I DATE
WSPECTOR
WL UNG APPROVALS
Set Sacks 70 -ZT- j-1—
MECHANCAL APPROVALS
Underground Ducts
Forms & Footings
Slab Grade
C
I0-
y
Ducts
Return Air
Steel
Roof Deck�A� L
,/ - $ _ Gy
Combustion Air
Exhaust Fans
OX to Wrap
Framing
/.� /D -!J/
�-���J
�
F.A.U.
Compressor
_
, -_—
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
_
_ _
Vents
Grills
Fans & Controls
Condensate Lines lo
Party Well Firewall
Exterior Lath-pIS
Drywrall - Int. Lath
(Final
POOLS S o SPAS
o LOCKUWQL L APPROVALS
Steel
Set Sacks
Electric Bond
Footings
Main Drain
Bond Beare
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
tonal
Gas Piping
PLUMBUG UO APPROVALS
Waste Lines��� (/� N -
Water Piping j
Plumbing Top Out�z �p.� °c
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Laterad
Semr Connection
Gas Piping
Gas Test
Appliances U
!� -z� -L >
-�
Pool Cover
Encapsulation
Finan
COMMENTS. .Dik �,sA� S • oa y.�� o �.�
QCs
rFonao�'=%�
Z 5
Utift notice (Gas)
•- -c��.
E LECTG3U AL APPROVALS
S
Temp. Power Pole
Underground Conduit
'
Rough Wiring
Lora Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Utility Notice (Perm)