9812-130 (SFD)W R•
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
t;5>t"lsi�l5 kT
&'30,', 0
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:
( ) 1, 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 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
performance of the work for which this permit is issued.
(� I have land will maintain workers' compensation insurance, as required by
Set;tion 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.STATE IFUND
(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 fortF with comply with those provis
mate: 1 !A' G ,Applicant
Warning: Failure to secure Workers ompensation 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 -'V06-
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 t0l
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 per6t 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 >>d.
BUILDING PERMIT FERMI.11.11) r
DATE VALUATION S.2•33,748.,% LOT 13 TRACT '29797
17_ 7_1 -
JOB Slr E 1 7,9435 •&d).1< ONJA
APN 76'3-��604)Y0
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1a.rT HOMES=
1U 1' IN, rNk i: -i !-MME NTS, INC,
SIO
1425 & u7NiV13RSITY DRI V
LA QUINTA. CA. 922-1
PH(-.)RN'1X.• AI 85034
C L# 4991)
-a+c
USE OF PERMIT
Sii OUR FAMIIi Yi)Wi+. AANCr
1
LOT 38, PIAN 3Al2.i3: 3 ' � - PERM1 i' DOES NOT INC UDE1' LOCM. WiikLLS
Ott POOL, PLAN CNEC k 1 E13 REDUCED 75% FOR WLi'1J LE, ISSUANCE, O
SAWPLAifTYPE. ;.
� S' OXO CONSTRUCTION �i3a<+ttifi
E�iIRGIUI'JaiTi? 000 Si:
c��tt�OsxaCn�.�c:�1't`1' • s7t�;tu.1 s!:
CIONSTRUC."T10N FEE • 101-000418-000 $11108,50
#'i. ,kN 4';tr!if_'`K } M, 1.01-M-439-318
AMEC1rr�NICIA1.. f�L� 101 -OW -Y21-000
.It. JX- ,*i 0AL IME; 161-000420.000
PLU:N031NC3 FFX 101-0000-419.000 �1t1Q.St)
1014100-241-W0 $73,37
GRAtSiNG IFai .. .101-00042MOO vaoo
INi'�£iWiRIXTbllt EEM 225-000-143-3Q -$5.220.
ART MPUBLIC PLACES - RISK, '701-1)00.255-41x0 $a34.7
SIM -TOTAL CONNST IX710N.i1ND RLAN CHECK
$7,386.90
1, y- LESS PRE PAILS FEL? -S
EatDEC
$0.00
2 X998 3701'Af, PERMIT �; -.EWA a UE NOW
$7,3»6.90
RECEIPT
DATE 'i
BY
DATE FINALED
INSPECTOR
.A.
5.:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings
/
Ducts
Slab Grade
— L
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
- fjf
Compressor
Insulation
—1
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
- C' rct
POOLS - SPAS
BLOCKWALL
APPROVALS
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
/ A2—
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
COMMENTS:
Final - U. !�
Utility Notice (Gas) 1 7- .. GU
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)