9905-240 (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
6377252
Date
to ` .�� 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:
( ) 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).
()
lam 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:
( ) 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 Policy No:
R0YAL INS. M OF E . PFC, 4.%9.;37
(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 tho provisions.
gate: Applicant �•
.t
Warning: Failure to secure Workers Compensation coverage is unlawful and.
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for. a permit subject to the conditions and restrictions set forth on his
application. -
1. Each person upon whose behalf this application is made & each person.at
whose request and for whose benefit work is performed under or pursuant`to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date''
V 1
BUILDING PERMIT PERMIT9S-240
DATE VALUATION .x'9124,336.30 LOT 40 TRACT 28601-1
JOBTSITE,ADDRESS 47- 5 SILVERIIE;RRY S'IMEET'
APN "9_03"20.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C.�'t'EI LL: RE'S21�1,iv"'!'tt1L Ct)MNIC.l1`ln I.ES,
fNt C,�.'T1±'f LtiS Ri,.S1SJI n -,Al.. C(•Ai�1S'f'attl�."T1ON
:y PAHA PLAZA, SUITE 400
5 .PARK. PLAZA, SUITE 400
IRVINE CA 92614
INIVINC, CA. 92614
(949)251-6100 CB1,4 5672
USE OF PERMIT
SINGLE FAMLLY DWELLING
9-T) -11L PiN
Tli.t�C7 f'C➢4�h'I'tl i� i iC t 21097,00 Sr
1.70RC HAAAT10 1.24.00 Ski'
OARAtlli,1C;.A1tF'OWF +13f).GO W
F-STfiATED COST OF CONSTRUCTION
x.241,3+ .30.
ff:l<'$MIT FEE Si1,1`1�'MAkV
C;U2+fMUC FK N FEE 101.-0004-18-Utl(? �7"27.rj4
RfWAN fl -TICK r. EE MO. M
rv�:t:,`%I.>NICAL AIM -101-000--42;1-000 St°6;50+
8LEC`.IMICAL FIRE 101-000-4-M-000 $.130.90
Ni:;VINIk1INCT f'>�-V- 101-0004W-000 164.60
c, tltflildCl A� >� 1C1P�7 a,fF R.3?`it.t 10!-W-94,1-000 12.0
GRADING PPE3 120.00
i` fIRASIRf3e:7` AT3FEE 2125�000-41.3-:1 -2 $2,7604
AKI %N PUBL:t4 PLACES - l ESIC 701.-000-255.000
t � ffi
i
a
547.29
199° LESS PJW I'.ArD Fri M
$0.00
;4 AL PERMITI+'E:9N DUCNOW
$4,547:29 .
r^4"
RECEIPT
DATE
BY �`�
DATE FINALED
INSPECTOR
IN11
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
f
5 1
Underground Ducts
Ducts
Slab Grade
fqq
Return Air
Steel
Combustion Air
Roof Deck
QCj 7
Exhaust Fans
O.K to Wrap
_
F.A.U.
Framing
IryCompressor
Insulation
- t 3 -,r
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. N., _
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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 Lin esHeater
Water Piping
�7
Final
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
S
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) I -q _.44D �,
COMMENTS: