0008-375 (AR)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 J r Exp. Date
706410 05r 1/2( 2(
,Date,�''10'rll41 Signature of Contracto
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 of 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).
( ) 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 provid'ed,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 ZENITH INSURA'NCR ' Policy No. 7,042062503
(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.
/bate: �d^2�`t Applicant fr' 1� r y ✓.r! a 1 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. 4
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 persont
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 informationis
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.
/ t ,- �� r:l
j Signature (Owner/Agent)? .I, Date � 7 /ty
BUILDING PERMIT PERMIT"
DATE / VALUATION LOT 0O08_.37.'� TRACT
Tom' c S 70,tlli?M
(f c
JOB SITE
APN
ADDRESS 79-MTOM FA7101:i.�'.i,N011 N.
76Z-522-001
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TUR -PIN CONMt =014 Co.
11 YRPTU 100145TRU'CT10N CO.
78-120 CAS F.S'I'ADO 41206
70.120 CALLS FMAD0 #206
LAQXMUA CA 92253
LAQXTMT'.A CA 92253
(760)'7777611 C',k1.TA 3751
USE OF PERMIT
R.��..�17AWJAL ADDMON
",MODAL 900 SV MR.A017, & ADD 8011 S10 t?.91'i.ACe,, TO 9XIST[NO SiVD.
CUSTOM CONSTRUCTION 96140 SF
XS7'f..MAT`Kd3 COS'r OF CON.'v'MUC rION
70,110.00
PLAN CHECK tER 101-000-439.318 $33010
CONSTRUCTION MFE 101-000-4103-000 $309.00
MECHANICAL FEE 101.000.421-000 $30,110
ELECTRICAL FEE 101-000-420-000 $30.00
PLUMB= FEE 101.000.419.000 $35,00
S11ZONC1 MOTION FEE - :}iWID 101-000-241-000 $7.02
i
E.
SUB-TV.1! VO b�`rAU(°3`TON At3"t P1 AN C%WC X
$981.86
,
r-: �'���rF IMS PF'.F-PAID FFM
$OAO
ASG 2 5 L: - m MWIff FXU DUE NOW
3li�6
RECEIPT
DATE r
BY ' '
DAT NALE
INSP OR
1
�J
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -dam
—
Underground Ducts
Forms & Footings �/ Gc _
Slab Grade �/—
Ducts
Return Air
_
Steel
Combustion Air
Roof Deck ��_� . C,e;
Exhaust Fans
O.K to Wrap
!
F.A.U.
Framing (
Insulation Cf
Compressor
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 Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines-� _ ri
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
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: