9804-074 (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
1 / :12l31I��9
Date !/ Signature of Contractor `�(' %/t(_
OWNER -BUILDER DECLARATION /
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) rhave 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.
(t Z 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 Policy No.
ST.kTL: FUND 6263.5547
(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' compensa�on provisions of Section 3700 of the Labor
Code, I sh II for4hwitfi comply wi tPigse provisions.
Date: : •' (« Applicant l.7 I•+' L r�
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 propertyffor Inspection purposes. /J
Signature (Owner/Agent)//r r f�" ", Date
BUILDINGPERMIT PERMIT#
CONTROL#
'90114-074
DATE VALUATION LOTTRACT
AR
4113
JOB SITE I
APN
ADDRESS 79„,"I SIENA COURT
OWNER
CONTRACTOR/DESIGNER/ENGINEER
EXCHANGE ,I I.E. G P,(:A.TP -
- RO'CIER 5NELLENBEROER
L.. ASSOC.
"s8 -6i3 NAPLES DR
"78615 NAPLES i3ltVE
LA C UIN f.'A C'.A 92253
LA QUIN'TA
CA 92253
060)772-4222
('. Birt# 18S8
USE OF PERMIT
SFU LOT , PLAN 313fc. P}:,RW WES NOT iNc."i UVFsi"DL0gK VALLS OR.
_
P( )L. PLAN CHECK PORTION f F FEE.11 RE;UUCED 75?%FOR MUL.'i WU_
-
ISSUANCE OF SAW PLAN TYPE.
TRtk(-.r C0N3 rRUC IC,N I.I.,ozi.00 sr APR
13 1998
PO4(0141ATIO 52.00 SH'
OAKAC3k'1i;ATti-TORT 4-W.I.W:32' .'T`
i
L '�;��1I�1T
b
CWT OF CONSTRUCTION
a
I'B;RI%Iif'1< ME SUMMARY
C;ON.TMA.l 710N FEE 101-000-418-000-1. 00-. $70-9.50
r
PT, AN C' HECK IFFT3 101•»4{1439.318 $146.98
NILC`JiANICAi. FEIE 101-(i(?0-421-000 ' S53,50
r1i,EMIC:AII FEE 101-400-420-000 $123.16
PLIUM33T ` O F laF 101-M-41.9-000 $ I40.75
TI R NG MOTIC N FEE - Rt -1.330 101 -OM -241-000. S11.9.3
CRADINI GFI 1014)W423-000 $20.00
INFRASTRUCTURE M, 225-000-443-342 3Zb67.(A
ART IN r'LII3IA .. PLA M- - RE3U; 701-400-255.0300 318,1.3
SUB- (IrAI. CONSTRI tC 1' ON AND MAN CHECK
LESS PRE -PAID FEES
$0.00
TOTAT, PERMIT F'E€ V DUE INMV
$3,926.59
.'j
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 Deck9,
Exhaust Fans
O.K. to Wrap
(e — _ Q ,
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 APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
�•;
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
2 3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_� 3 —
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)