9905-021 (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
iw
714188 ' 1(113111
Date,i -° '" r, f / 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). '
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct.the project (Sec. 7044, Business & Professionals
Code). ' j
() 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:
() 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.
- GOLDEN EACpt�17lNS. 14WC 544063-01
(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
Cro'de, 'I shall forthwith comply with those provisions.
Date: 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. l 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.
Sig nature (Owner/Agent) ' '' �'� _ .1 ! Date
-• - i.
BUILDING PERMIT PERMIT#
)�
DATE VALUATION LOT -�.tel}.-�TRACT
239,95-6
JOB SITE I 'I ' ' —^ ---- —
APN
ADDRESS `" 4S:545.% -r0 1ERH00K COU I'
`
*`t1�+ )40.1116
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C1rtv'"1'i 1CYCRIONVEL.1,.°'0Mt,4%fN1f111S
�tW1triRyCii{J1Y, F. k. COMMIMMES
1535 $U. "D" ss' r. t t', S`m, i1 oo
153.5 SCS. "U" .13TR I T. STE, 9200
SAN BE,KINACDINO CA 92409
SAN BERNARDINO Cit. 92408.
(9109 3R:}._6w,/ 9'r`K41 2120
USE OF PERMIT
S WIL rill�is. ' ,l�v►jELl 1Zvr�,
S.r, D - LOT :12 PLAN 5k3AR - i': MIT DOESS NOT INC'` WBLOC & 'WA L
O•K POOL. w7S% PLAN C;4.14iE:bCFI% kQ)'UC.'" rIUN FOR IMUL"t'A?IX ISSU.AM,18,
OF S.AMR FLA: TYPE. `
€T ld"s" Lt%t�t;e'[i'v�CTs'O�i 10,04.011 Sr
GA A OU -CARPORT 416.00 3
ESTIMATED COST 0ri CONS
PERMIT r+ FIC SUMMARY
CONSTRUCTION FIRS 9991-M)-418-000 569+ J)o
PUktN r, REP, MIF 10t.43W-439-3t.8 S144,23
IMECUANt.C:ALF''4M, '10.1-()�fy�4i1• 547.00
�.ks'f'CUC AL FU 1911.4)0-42.0-00 $126,442
4?LUMf3INo 1W 1014M-419-000 $134.75
,.%rmwo MOTION N tit? »� RFtiu'4„� t. tlt -W-241-WO $11J-68
GRADTNO Fa, t:01-1100-47.1.000 320ACXJ
IT-4171ZASTRUCTURE FEE 225-0W443-342 571626,96
, W.V IN PUBLIC PLAC'US - RESIC 701-000-255.000 WAS
{
Sr�LTcYCA Ct��iS'1'i2UC'1'IC)N QNf Pr�A �,tTt,CK
$3,8!2.32
LM PKK -MD FEES
$0.60
TOTAL C'N tTwI#' F14,3 5 :01iIP, NOW
$3,#52J2
RECEIPT
DATE
BY M= ^`'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade IVReturn
Air
Steel
Combustion Air
Roof Deck
- ��
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
—2 —y
Compressor
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final Z-- --
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 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
.o _ Pf
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: