9806-009 (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.-;
,s55(i5 13 t'if3Giv9
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury'that I am exempt from the Contractor's
License Law for the following reason: 44
( ) I, as owner of the property, or my employees with wages asjtheir 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 pr6perty, am exclusively contracting with, licensed
contractorslto construct 'ke project (Sec. 7044, Business &,Professionals
Code).
() I am exempt under'Sectlon B&P.C. for this reason
Date ` ..Signature of Owner
WORKER'S COMPENSATION DECLARATION
1
I hereby affirm under p�egalty 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 nrpintain workers' compensation insurance, as required by
Section 3700 of the LabortCode, for the performance of the work for which this
permit is issued. My workers'. compensation insurance carrier-& policy no. are:
Carrier Policy No.
ate, A t'i:�m 7 G!i ,fit ..9T,� i i4r'. 1' i.�ii u�
(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: ADolicant
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. p
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) Date
BUILDING PERMIT PERMIT#
980&4J09
'S +R •'1'1
.DATE VALUATION LOT TRACT
.1 MOM $120.486.:30 11,12
JOB SITE
ADDRESS 53 -UO A NWANrinSCO
rPN
1
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MHN P DYCK
u rlAl:ri L SIVA; /'E
7494 SHASTA HORES"', UIR
PO .BOX 51161 I,..A f,?L.1iwm CA 92253
-S-13"1r1GT.,ery..)WN CA 96088
CAN'1'O1+1 %AKF C.'A, 92587 ..
(760)7'1-5452 GIBL9 1794
USE OF PERMIT
S1hIGf�F i~.A11'�Il,,'I` ,��A7-l.t,l.,EAicy
'
Slip - 3�"CR1uE ` 130)rS bi0'l' INCLU_X BLOCKWALLS OR FOOL
L>
` RUIC`1' CONSTRUCTION 1,977.>riD SF
K)RCH1PA'T10 64.00 3F
UARA.t;.Oc AKPQRT 540.00 8-F
6 FT. WOOD:lP9fq 'Ji 200.00 LF
ES T IMXfE P COS OF 6.11`+'5I I$�C"I «s31di
120,486.30
s';CJNST'RUCTIC)NFEE 10.1•-000will.84)0U 713:titti
Til:, AN (11K ;1` le i?; 1011-f- .-a1.,3ID- t 111 $613.4?
,NU3 ;UM4iCAL F=FX 101-000-42,11-000 371.71,00
E L EC, €"111CAL LE $190.1130
PLUM6'1NO FLZEs
S`7!'RON(I Mot 1t 0'N FM - gh-M) W-000-244-000 -000 $1.Z 5
flflf?.32AS1R6CT'UT,W, FEE -12 5-0�.W-443-342 $216331A
ID(Rk D;1'[3.i3:LrYIV -101-0W-441-.345
E UE RPOS1.T 101-000-43'1)-315 4250M
SI.113-TMALI I CONFYRU(MON AND PLAN CHECK
$4,502,73
- LESS+ RU -PAID VERS
4250.00
- TOTM, PERM.IN F LEN DU NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
I%
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings YX -ksW
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
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
POOLS - SPAS
BLOCKWALL 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 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
COMMENTS:
Final'
Utility Notice (Gas) 07
ELECTRICAL APPROVAL
Temp. Power Pole t
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) s