9905-020 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I amlicensed 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
r 14 11 88 H
yDate _ 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). '
() 1 am exempt under Section B&P.C. for this reason
Date Signature Of Owner
WORKER'S COMPENS TION 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.'
�C31.L�:T'14E NGLER143: 54068•UZ.
(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
supject to the workers' compensation provisions of Section - 3700 of the Labor
0ode, I shall forthwith comply with those provisions.
Dater' Applicant "�^\ r -Y - • % r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in.Section 3706
of the Labor Code; interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a` permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ' { -L t Date i` _ r
BUILDING PERMIT PERMIT
"015-1020
DATE I VALUATION �,,'�•�'� LOT TRACT
fir.
JOB SITE
APN
ADDRESS 'IM 1T'�.1)iROOKL�'�1jRf
604-016-0162
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CIE'N"URRYf',.ROVIILLeOMA.SUNIrMI�S
1535.SO. "TY `#'ItM, X.M. ra20015
5 so, "D" .Z 1'REF.1'1''. S'1'E. #1100
.SAN "MNAfC,CiINO CA 92401
SAN W-RNA1t1 INO CA 42408
(9091Ait1.0117 CRT,# 2120
USE OF PERMIT
SiNGLIR, FAMILY %1YEJ.,ialNG
FWD-1,t;i1' 11 PL AN 28 - PliTtWT DOES NOT IAT(:{ UDE Rf.O r'1Z Wi". Ck
.F XXL, 47Y,$ PLAN CHM/.'.L: FFiS RI-DUi:'PiC3A1FOR t4111?;`..•ITPt:i.- lk SUANCE OF
,4AMEPJ.'.A!Y'F'S 'L
TRACT CO) t'RUCTION 1,460,00 SF
GAtY GIa dCAR,C'4aWF 413.41? .
'€.71 -ON
37,72.,510
C'euNMUCTION Ff.1E• 101-000-418.000 $5&1;J0
Pr A:t COECK YET 1.014X,10-419-419 419 S M2.3Q
iVFFC:I3ANICAL f`1<? 1.0'i.^t900-421-0T10 $47.00
ELECTPUI,'CA'f FAT 101-00". 20-M S107.86
PLI TING F'VY, 3128.73
IR'f7tONC3',F4 O'('fONFFY - R113CP 101A00-241-1100
[iltrll?1Tit� ,1 � s 101.000423-000 &x19.00
1NF"S`1.12.t3M-RE FIE 2.'x,5-ii{Ji)-=d -342 S.L%5.89
NUB-TMAJ, C ON -"i i .1 ,1f'10N ;AND PLAN CHECK
$2,996. i 3
LESS PRE -MID TEEM -S
$0.00
RECEIPT/^,
DATE
BY'
DATE F
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 Deck
%— 7— `j 6
Exhaust Fans
O.K. to Wrap
—.2/—
F.A.U.
Framing
p _ _
Compressor
Insulation
Vents
Fireplace P.L.•
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q®
Drywall - Int. Lath
•
Final
Final —u - %
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APROVALS
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
Final¢t-
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-
inalUtility Notice (Perm) .
Utility
COMMENTS: