9905-018 (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
i'7l4libb E3 tt�'3iii:
,/Date' �' 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
Codey. -
(): I am exempt under Section B&P.C. for this reason
Date Signature of Owner
f .. .
WORKER'S COMPENSATION DECLARATION
I hereby affirm;uhder penalty of perjury one of the followi'g 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
perriit`is issued. My workers' compensation insurance carrier & policy no. are:
Carrier. Policy No.
(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
worker(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.
,'Zate:I- i.., in ^APPlicaht
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 a's 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) f ` > Date
BUILDING PERMIT PERMIT#
DATEf VALUATION $1.16,753.60 LOT Ir9 �'� TRACT X06 6
jjf
ADDRESS 7C,�s.«'sl+►*,T.��3lY�t R.lai.�I�Ya,�U�.i a J00 al I E
APN 604-040,016
OWNER
CONTRACTOR / DESIGNER / ENGINEER.
CUNW:;YCR01.1111_,11 IC'011AA11JINi''`Ui
C:t:NITTJt.YU101..1F.,LC0htkRtaNr.r11rSN�-
,1 5.35 SO. 'I D1 STA.E1 "i; ,':�i E 11200
1;535 Sia. "0” 9fHr. f, -'�M. 6206
1 ;E1€d [31;k7NAktl7iEti6i) CA 92408
1a�11� 1i�tNl.r^►l1�(1<t(7 C[3 X3240$
(Sii a��R1-�> tJfi CALA 2.1201
USE OF PERMIT
9 - LOT 9 PLAN 50t: - PgMiCi i .NU:f INCLUDE BLCC.K WALL OR
POOL. *7M3ro PLAT4 CHFAX M :F.0"MUC` K N Ft' R. OF
. SIti:PLAN'1`5'�R.
TRAM' CONSTRX.lCTIOIN ZOOO.00 it
C' Ai A.GGl;/CAAI 0Wf 4Y6,00 SF
/
e
EST 1AIAIT 1) C0ST 01P C07.\1S , UC-'10AN
116,7,5 x.601
RAS 1 T 1>''ER, 80611M A►.'KY
(-'+i)N!KfRUC71CON F tT 101.-()t1()-4618-000 $699.00
PIAN C'11iFCK c.F S 1Q1 -(>(y()--139-318 $1442V
1LSI t 13ATd1CAL 101-t 00421-000 547.00
E LWI'I2. CAL FEE 101-000-420-000 $1.26.82
PLUMBINO FEE 141-000-419.000 ;$134.75
3TRONOT'MOTION ('?a - k it310 101-(1p(i-.2411 AMA
GRADIAN3 ME 10.1-OM423-M
INRtXS'tR(fC.'rV VIM. 22.5-000-443-342 $2;626.96
ART tai' PUBLIC P'LACCES -1dE$W '101-0W255-000 $41.88
SUBIFUC .L CONSTFS Cr,101N AND PJAN CHECK.
$3,fty 32
CESS R&.,r T.D FEES
$0.00
`t0'fAli P1i+.>RMIT KUY 013;C NOW
'%J.4152.32
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 Deck— ?- 9 5' 6 /�-
Exhaust Fans
O.K. to Wrap g,/7-99
F.A.U.
Framing `L
Compressor
Insulation _ 3v
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
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 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 — Zp 6
Pool Cover
Sewer Connection
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: