9905-014 (SFD).f
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
71ai �0131;1�
4. a:
vDate t / t Signature of Contractor—1
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
( ) . I -am exempt under Section B&P.C. for this reason
Date Signature of Owner,
x
WORKER'S COMPENSATION DECLARATION
1 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.
Se( ') I have and will maintain workers' compensation insurance, as required by
ction 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:
Cartier Policy No.
t z
i31;t4 l ACL'R WS.N"AlC _U068.01
(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.
ADate:,t z? Applicant rN", � "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 �1
work is not commenced • within 180 days from date of issuance of such y
permit, or cessation'of work for 180 days will subject permit to cancellation.
1 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
t16elabove-mentioned property for inspection purposes.
d gnature (Owner/Agent) j�►# ' !" t 171 t Date I
BUILDING PERMIT PERMIT# -
'1r1U5-1i1,�
DATE VALUATION }116,753.60 LOT r TRACT
JOB SITE
ADDRESS ` � 4, 5fONFET1�1 O . CoUR
APN 604-040-016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
rp> nr �lS v r> rs t t ��r„+� PaT„P,rrvit,c
.,.rlttti a. L\. YV a.�"t.,# l,.+.�t. a 4.+ VA• FA✓
rrn��`I�'n�r r+t>rj�arr� r +r�i�r� tt I dJM 5
l�aa ♦R Lw. h,1 L, ..Id .kJ/ 1. VINI 1,
1535 SG "13” S'i'iM61, Mi. #200
1.. 3.5 SO. "0" S"°lr'lZFVr, S 8. #200
SAN OMNA KO NO CA 92408
SAN l3iiKNA1il I NO CA 92408
(909)m 1-6wC811# 21120
Y
USE OF PERMIT
XA14JI .Y Uiii+k , ,. iii
si,.LD - t.0 7' .5 PLAN 5CAi - PERMIT D06S NOT INCLUDE WALL
cw i 1,. y r
MkCT LIONWI UO,1 s034 2.OW.00 SF
GARAi30•C1l1?.aUk1' 416.00 £tor '
_ t•
F,STIAIAT ED CWT Oft e`.Wk-AlI►O`
126a753.60 sr
7l\M3A RI[tSUpVRr
C0101.RUC-710NFF !0l -f1 l=!•! -�00 �ts99.(►41
i'1, W CtWm WE 101-000-4?W-:31 R $57F.93
;vCCHANICAL = 101-X10-421.000 $47,00
OXICrfRICAL 101-4W420-000 $126.82
PLilTVfi1 ING FIX 101-000.419-000 3134.75
M_0. NQ M0T1()04 FM - RES1D IM -OW -241-000 V 1.611
GRADING FEE .1.01:-000423.000 W100
1NFRAI,Ti'iMTf(J[t1;:taFE 22.5-00",43342 VZ626_'1t6
ART INPUBLIC PLACES-,RjVSW 701 -W0 -2,55-W) $4.1.88
;H9 TV1"1114 T! Q 1.Ot1Ct-430-Z t $-g2Sfl,tni
SiJ1Vr 'A.L CO3N, ?,(5C'S7(_N AND PLAN CHECK
07
LESS .Ply -PAID FEES
4250.00
TOTAL PERMIT ➢ EFF—.1t DILI s NOW
S4,0_35,01
t�
?r'
/.tit L.
ECEI.P.T
r
DATE.
BY "
DATE FINALED
INSPECTOR
If,
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
Exhaust Fans
O. K. to Wrap
_,/ _19
F.A.U.
Framing
Compressor
Insulation
--2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
�Z
Drywall - Int. Lat ,e ,,;I-
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
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
AIL
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) fI
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Z
Fixtures 1114
Main Service
Sub Panels -
ef
_01
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)