9812-128 (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
• n�ik��a� � � � W3(),Iu6
Date y Signature of Contractor `f
V
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).
( ) I am exempt under SectionB&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.
:�TKITE FUND
(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 -p ions.
Date: Applicant ti
Warning: Failure to secure Worke s 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,toAi
any permit issued as a result of this applicaton agrees to, &shall, indemnifytV
& 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 'k
work is not commenced within 180 days from' date .of issuance off such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that.l have read this application and state that the above information is -
correct. I agree to comply with all City, `and State lavlis relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
�
>gnature (Owner/Agent)- i Date
6=5t- (;r -
BUILDING PERMIT PERM'S
DATE VALUATION S2.33',74I,g0 LOT 36, TRACT
JOB SITE
ADDRESS A/19L315 T0R43N A
APN 769-"0-010
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JT'HOMES UC
PC) BOX 8.10
1425 E, UNIVERSf.1'YDIUVE
1,A, t)U!N'VA CA. 9.2253
PRO.f N'IX Al. 85031
t7�)2S7� 1 #i5� CNA . 4
-
USE OF PERMIT
S:NOU, FAMILY UWE'LL.ING
LOT 36 PLAN? 3ARGi $Fly •• P.EMIF C DOES NOT NCLWE BLOCK WALLS �
OR POOL: PLAN C%EC FIE Rs-DUCFD 7 -Wo FOR &llt7..Ti7'LE 18SVANCH OF
SAME PLAN TYPE.
CUSTOM CON°VIRUCTION :,.833.00 SZ~
1}klCfi/sAT'1) 110.00.
OA1r1iQWCARPO t' 578.00 SF
iii�t�"� E D COX ' Old C�31�`�T1��7 Nati
4.33,74�.30
y3}��[� � y �
gg 44,, y gg�� jj PCESUMMARY
4CONSTRUC'TION FEE 101-000-418-000 $1,108.50
PLA -3 f,;1ffEC K'FIVE 101-000-439-318
NI'ECRA,INIC'AL tRF 101,-{i00421-000 S10100
�s.�:R, Fk1CA1, n- :E S 168,,2
:PWA IH'ING FEB 10.1-000-419-100 s1 ,.Sc►
aTRONCI A1t�T !01%1 IFFE I�SYD 101-ULiO-?•�!1 ^f1t10 52317
GT2ACILtdCi rEC1 X101-000-423-0012 V2n40
11>[f°1TAS':1RUC'iMi"111E P` 225.000-443.312 $5,220A*
_
ART IN PU13L1C PLACF-9 - Rtq.43 .A)1-Etfl'!.l-2:5:5.000 $334.37
s
.FR
'• 'yJJ'^ y ArA LJY. SIf,
VClMAND PLANCHIBCK
g !y3R6,90,
.t LESS PREPAID TS
$0.00
t
T
- DEC 2 1 ` AI, Priu n- ��;1 s ���a�; sv��vv
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[A�E,CEIPTk'
DATE
BYk{til
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
Exhaust Fans
O.K to WrapV
F.A.U.
Gl
Framing
— G�GL
Compressor
'
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
C -
Final
� GJ
Final —a
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
0Encapsulation
Gas Piping
Gas Test
—GzJ
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: