9812-122 (SFD)LICENSED CONTRACTOR DECLARATION
!.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
o� a6i0100
V ate`��� 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 dor 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).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
rWORKER'S COMPENSATION DECLARATION k
I
I hereby affirm under penalty of perjury one .of the following declarations:t
() 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
Sectiori 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.
"�t'ri3`�.Pi12d'D U3s-S�o-123"v
,.(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
work6es' compensation laws of California, and agree that if I should become
subject to the workers' compensation provis��.nns.of Section 3700 of the Labor
Code; 1 shall forthwith comply with those�P• ovisions
D(ate: Applicant
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 4
& 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) Date 4, r ayr.
:s=.. BUILDING PERMIT PERMIT"
DATEVALUATION LOT 9812-.12-2. TRACT / fv
! 15 28797
JOB SI,TE ` (
ADDRESS
79-344) TORONJA
FPN
769460-0155
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER .
Ur HC MELTS I.1..l-
RIT 1NV•CST &-M 'i'S, INC.
0c) Bc)x" $:to �.'
142.5 E. Uh1IV8R.SrI'Y ORI\1°lr
LAQL1iN'.f'A CA '92253
PHOENfX AZ 85034
(b02)25?, 5$56 C -BL# 4990
USE OF PERMIT
LOT 1.3, PLAN 2BRG. WD - PD i G BOSS NOT iNC'L1J/-DR BL0CK WALLS
015. POOL.
- CUS TOM C;OAJTfRLICI`4014 2,517,00 SF
`
PORCRPATiO 203.00 SP
CiAILWE'CARPORT "'.5k.00 k.00 SF
x;1141 ATED COST OF CONSTRUMMIN
2.14,955.40
PERMIT FEE 3l3iviMAR
CONSTRUCTION FEE 101 -NO -418-000 $1,042.00
PLAN CHRCK •fX- 101000-439-318
ivlECflA1VrICr1i.1" E •-003-42.1 -000 $1 1.1.$0
101
i~ SCIRICALF.FX 101-000.420-000 X159.34
PLUMBING FEE, 101.-000-419-000 $180.s0
STRONG N(OTTON FEE - IlEifD 101.000-241•^000 $21,49
C'gi�ty2(.!ADINtrpi��EE 101-t�)(00-442'3-0013 ztl�,tQl(ti
�j�]j� (,yy� Q'�
_ �.IV3 RA,S✓titV4�+'_1lJRA.C•,EE 22«"•000-43 -3-41 J4,77J.50
AP -.,T IN PUBLIC PLrkCf S - RESIC; 70:1-0W255-000 $237.14
C
COAiSMUCTION ANIS PLAN CHECK
$7,453.34
1 J'
LEI Sa �'.10E-PA1f;1"EGS
; °�t?.Ut1
DEC. 2 9 :'1998
TOTAL ;k"FRr*117 .FEE'S DUE NOW,
$7,453,:54
,j to
RECEIPT
DATEsBYr:
yrj }t
aw
DATE FINALED
INSPECTOR'
y
x.hi.
2;.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— O
Underground Ducts
Forms & Footings
_ 6 _
Ducts
Slab Grade
C (
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
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
lo -
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
0
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) 2—Z2— 1 `�
COMMENTS: