0308-089 (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 f6rce'and effect.
License # Lic. Class Exp. Date
777699 $ 04130!'.Tt
,Date Signature of ContractAA A/��'''�'"'
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 undeF 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 Qf the work for which'this permit is issued.
(,) I have and will maintain workers' compensation insurance, as required by
S66tion 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 ,G113TkATY MUTUAL K Policy No.' WA36 WO4721012TI
(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 s I'I, f9grthwith comply wit thos�,Pr,9,u to s.
Date: M l� Applicant � 1 r_ V ��
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 t6 '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) -�/1st/%'^°'" " Date / U
BUILDING PERMIT PERM T/1
l'
7lJ�9�^ii[73
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 50-1
u VIL11A. o DIMF
APN
'77.7-.250-011
OWNER
CONTRACTOR/DESIGNER/EN INEER
'13-121 FRED- ARTNG 9-100
7:3121 Fms, G 41041
PAI<.M DRSERT CA 92260
PAIN, DESk RT CdA 92260
(760W74p9699 4.'13T;R 3832
USE OF PERMIT
SWG1Y_ F.�►M(LY D'�L1 ZTG.
SFD s LOT fat; SEDONA. A. PERMIT DOM NOT MCLUDE BLOCK
WALLA P0014 BPA OR D1Tf-AIWA'Y APPROACIL 7W REDUCTIaN TO PLAN
GHECK I%E DDE TO muL"1'IPi:E FSSU.AaiCE Oxip S;Amr,. PLK'K TYPE
CUOTOM (!0H2TRI,kTI'0N Z800,00 1W
PORC1'IIP.ATI0-� �' Viop SF
GA1:At1ElG';A1tFORT ' /, fa10,Oq sw
I` N-r1A'It 1X D COS OI' 00240 <2a3C`.7�;OX
317.V.50
PEDAW, f;f CE UUMM4RY
CONSTRUCT1011 PER 1,03•4.m
PIAN CHECK 1n $237,00
MECHANICAL FEE 101-000,421-000 X111.50 .
ELECTRICAL FEE 101-000-420-000 $166.20
PLUMSTWO FEE I01-000-419.000 5194,00
STIZONU +M OTION ME - 18.E S]D 10.1-0004AI1-000. 533.3'1
G13A DIi3C FRE 101•000-423-000 81S,Etil
1DLVELOPZ1; IMPACT F.E.? x,405 fs0 '
ART 114 PUBLIC PLACES - M211t 270-000-W-0100 .984.3I.
C TRUC7100 AND PLAM CHECK
$4,:324.90
D 2 6 Zo03LESS PRE-PAID.FEM
$0.00
PERMT PEEN DUE NOW W
$4a324M
Op IA GlU1Nt0` _
C, pEPT
`
F p`�GE
RECEIPT
DATE
BY
D
NSPE OR "
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel 1A
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap ..
Framing
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
�
Final
BLOCKWALL APPROVALS
Final �
P006 -SPA
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING P VALS
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.ZZ
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: