9810-059 (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
69064.5 B 45/A(f/00
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 theJProperty, 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). 11
() 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
pe ermapce'of the work for which this permit is issued.
6 . .ave and will maintain workers' compensation insurance, -as required by
ection 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:'
S';'Ad'r'E"1?i3,''Sl3 itt5.3.22:..
r.Y.
(This section need not be completed if the permit valuation is for $100.00 or ess)7:f,'
() 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.
Date: Applicant—f, ,
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 hist
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 appllcaton'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 v4 4.
work is not commenced within 180 days from date of issuance of such • �F
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-meegtioned'propertylor•im�eet�An purposes.
(Owner/Agent)
_Date
PERMIT # CONTROL #
BUILDING PERMIT>.8>_®
DATE VALUATION- S-200,1".20 LOT 20 TRACT -2814,07
JOB SITE
ADDRESS f�S 79-29® ORONJ
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
_ _ _
1tIT NOINIES LLC
,.J'1' 1.NVES'1` IM.N-f-S,1"7C.
1O BOX 910
1Q.5 E. UNWiR.SM. DRIVE
Ltd QU(NTA CA 92253
PROENM AG 45034
(602)257-.I6M CIUA 4990
USE OF PERMIT '-
f
STA;OLE, FAMILY DWRLL 140
00, LOT W 20, PL AN1,1 OWT DOES NOT INCt:UIU11 BLOCK WALL OR
POOL.
CUSTOM CONSTRUI I a.Oi3 i ' 470M SF
112.00 Si-
0ARAGEIC ARP0>10 6: i:tht SE'
EMII T. D CWT OFi:�� iT�aUCSON
.c.
2,06 172-.12.0
PERM 'ti' FEE E SUMMARY
4.CJN:3"I°Akfi0fION FEIN 101-000-418-000 i;tiZt;,f. a
u,11, ANS r,.1•TECN, F1'FF, 1 t�R0
q�35,5r�
'10J-000-41271-000
E'fXC'1 TICAL FEE 161.000-420.000 $156.47
PJ1Uf fN0.hE__E1 10.1-000419-000 S180-50
MC?NG MOTION FEE - RPO0 101-(it1f9-141-000 $20,67
GRADING FIX, r' 101.010423-00n 32614
TNF PR A:a`f EtiXTiJ121`s f RE 226,4� 0^0.'-443-342 $4,6051-M
W , A£ I1.' TN 1'UBL'1C PL.AC.l S - RE13[P,101; [3W-7,55-000 5265.,43
x
'AL.6r tAi11'9 .� CHL-KK$7,02:
. j LESS !'U -PAID F'.C1:,S
-$.11.00
'4199a M
1
3-0} QCT T �a PC 1 owl-,
w,702..88
t
�..
RECEIPT' i
DTE ,v rr /�
vff LY//
BY
3�
DATE FINALED
INSPECTOR
,tea;:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
aj. Q/
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck-
U �'j
Exhaust Fans)
O.K to Wrap
C!G
F.A.U. -p
FramingCompressor
-
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-
Final GS
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
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 Piaster
Sewer Lateral
Sewer Connection
t
Pool Cover
Encapsulation
Gas Piping
Gas Test
/
Appliances
Final
Final 1-77
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
t
Final :L _
Uffly Notice (Perm) ��.
COMMENTS: