0308-086 (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
7'77699 P 04P.30i2C
Date R''' Signature of Contractor 4. ez1°�'""""
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).
( ) 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
Date i Signature of Owner
J
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 a:1BF27T, MUTUAI X Policy No. WAZ62D` 04723012TE
(This section need not be completed.if'the permit valuation is for $100.00,or less).
() I certify that in the perforlimance;�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 fo hwith comply with those prov sions.
' e; !hall
a Applicant_,4Z
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 upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)G�• � -@.t ^"^' Datef
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 'TRACT
$1S39774.20 SS 3017
JOB SITE ADDRESS W -3M y',11;.��.iti 0 D1�1''YF: . .
I. APN . 7'/.2-25"11,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOLL mor -mg '14cit'3Z,,LBR.C7C"iF_PgngcC
73.121 PrM WAR}1 0 4100
73.121.1I ETD WAX1:40 41100
PALM DEFRT CA. 92260
PALM Dr.2'•£a:1' CA 9.2264
(760)6749699 CSIA, 3832
USE OF PERMIT
MNGIZ FA;N&LY DT. two
SFD - LOT 59, HELIZ& 3/4' PATIO. P1 IT DOES NOT INC'L'UDE
BLOCK WA,LU% FOOL, SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION ,047,00 3F
13OrX.i•fiMAi'TIQ 31.160 SP
C7ARAOFIC;<#3'PORT 02$.00 OF
4
NSTIA AT'.1 D COST OF CO%7IM1:7UXION
253,774.20
Pimwffb%'y:' St1MKA1ZVr
COA STRUCT10N FEE 101.000.1.18.000 $1,176.84
PLAN C HXCK IEE 101-000-4.394318 sm,a
MECHANICAL FEE 1 f?l aclvt;-421 �CD(2k� � t5G,0a
E.LeCTIUCAL"A 101-000-420-000 $294,23
PLUM8INO FEE 101-.000.419.000 $203,25
1TRONO b/OTtON FEE - RFSID 101-000-241-000 $23.38
CTi.ADINtiM 101-000-423.000 115.40
DEVELOPER IMPACT FEE. ' $7,405.00
.
ART IV irUBWC" PLACES- R +T.f3)r 270-000-445-000 $1,14.44
IRRUkM, 0N At.(;a PILANM_, 2t
UsS Pk1.1?MPAU)1eW 3
$0.00 `
2 61003 Q3 AJI� PIS Ifff FTEN DITE NOW
s P
QVINSA
V FINANCfc ID
RECEIPT
DATE
BY
D INAIN
PECT R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs.,,,Underground
Ducts
Forms & Footings
Ducts `
Slab Grade
Return Air Y
Steel
9,_
Combustion Air
Roof Deck
Exhaust Fans OP A
O.K. to Wrap _
F.A.U.
Framing ok
Compressor
Insulation
Vents
_ _
Fireplace P.L.
Grills —40
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
01
Exterior Lath
Drywall - Int. Lath
Final
Final /� _
POOLS - SPAS
BLOCKWALL PPROVA S
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVAL
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPRO ALS .
Temp. Power Pole
Underground Conduit
Rough Wiring
_
Low Voltage Wiring
Fixtures
Main Service
Sub Panels`P.04 7
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) f\