0308-092 (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
fi 7'9699 B 0413044(
Date Signature of Contracto'"""" `
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). - r .
( ) I am exempt under Section , B&RC. 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 LIBERTY MUTUAL F.' Policy No. WA262=4723012TI
(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 fo hwith comply with those rovisiohsr��
^,Date: 2 Applicant
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) `�6 "r'� Z Date _�'.'9 �°
I
BUILDING PERMIT PERMIT//
-
DATE VALUATION LOT TRACT.
6- 'r''. 3 9,219,963.60 04 303''
JOB SITE
ADDRESS ,VF A.fl0 D.�VE
APN
i 72'a 4113 .
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TOIx. BR(ynU.M8 WC
:r0L. 3380TF S We
73-121 k< E` WAX(140#100
73.32' F L?D WlA'1 . 00100
PALM DRSE tT CA 92260
PIALM DRMT CA 92260
(769)674-9599 C S 0 3832
USE OF PERMIT
117 01 L F'AMJLY DVM,1. '(3
SYD - LOT $4, CAMIN.APA, PgRRMIT DOFX NOT INCLUDE BLOCK
WAUA POOL, SPA OR DRIVEWAY APPROACH, 75% REDUCTION TO PLkN
CHECK FEE VUE TO MULTIPLE ISSUANCE OF SAME PLAN TYPZ
CUSTOM t" NSTRU4;T1,ON 2,631.00 SF
PORC"'WPa TIO 399.00 SP
OARA,GFJCARPORT 495,00 8
R8111'lRrrKD -COST Oxy C0X6 'I?tt :0W
219,9tWA)
14UOM FJM 8iiMWAR 1'
C014STRITC;'YION FRE 101-000-4.18.000 $1,059,50
PLAN CHECK FEE 101-000.439-318 $2111.:31
MECITANICAL FE& 101.000.421.000 3124.50
RLECT, RICAL PRE 101-0007420-000 615'1.94
F LUMBINO rZt 101.000.419.000 $184100
S'TRC ,N-0 MOTION YCE - RESID 101-000-241-000 '612.00
GRADING FEE 101-000.423.000 513.00
D9VRL0PZR 1MPAC°T M. $2,405.00
'
ART W PUBLIC; FLAC0 - RFAIC 2710-000-445000 5491
W
!ONWAUC"'nObF AND PLW iii raK
43ta.+44
2 6
SEP
LA QUINTA 01TAL P 8 DUE NOW
$4,236A4
CITY OF
DEPT.
FINANCE
RECEIPT
DATE '
BY
DATE FINALED
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
Combustion Air
Roof Deck
i
xhaust Fans
O.K. to Wrap JeF.A.U.
Framing
/b
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
01-2 J7
Drywall - Int. Lath
Final
Final
m
POOLS - SPAS
BLOCKWAL
A PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING f PRQVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
dK
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
SewerLateral
A
Pool Cover
Sewer Connection
Encapsulation
Gas, Piping
Gas Test
Appliances
_
Final
COMMENTS:
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)