9712-067 (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 Division3 of the Business and
Professionals Code, and my License is.in full force and effect.
License # Lic. Class' Exp. Date
12/3119.7
Date (.t r�(w)Signature ofContracto/~
OWNER -BUILDER DECLARATION
I hereby affirm under penaltyof.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).
(,) 1, as owner of •the property, am .exclusively contracting with licensed
contractors to ,construct the project (Sec. 70441Business &- 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 acertificate. 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.
STATE FUND �;iti3�586
(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' compensatiori provisions of Section 3700 of the Labor
Code, I•shall forthwith comply with/those provisions.
Date: jl ( .i 1 APPlicant _ 3!1 + .11
a
Warning: Failure to secure Workers' Compensation coverage -is -unlawful and to
shall subject an employer to criminal.penalties and -civil -fines up_' $1.00,000, 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
fora 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 benefii work is performed under or�pursuant to I,
-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 information is
correct. I. agree to comply with all City, and State laws relating to the building
co,ristruction, .and hereby authorize representatives of this City to enter upon
thio above-mentioned property'for inspection purposes:
(� %
Signature` (Owner/Agent)- x' Date
BUILDIN�G`�PERMIT PERMIT# � •• - CONTROLN
DATE VALUATION LOT 4712,067 A TRACT
9
UM,154.66 7 6447
JOB SITE
ADDRESS 78-727 TORINO DRfVP, 9
APN
1� 6f19-06.10131
OWNER
CONTRACTOR / DESIGNER / ENGINEER
11
THE EXCHANGE. GR(aim, INC
ROGER SNEL%ENBE!wr, & A
1 FLORE'WfINA U1t
41-865 BC4REtDWAi.K,,§UI iTF.212
RANCHO MIRAGE. CA 92270
PA.LZl DESERT CA,. r 211.
(760)'/77-7766: E"L,# 1858, .
-t
USE OF PERMIT
LOT Y8, PLAN 4AR. `•
SM. PERMIT .DOES NOT 1`14CL1.iM BLOCK WALLS OR POOL.
DEC 16 1QQ?
V ITY^
A
TRACT CJNS'MUCT[ON 2.2130100 SF4�i1WHA•
;
PORCHfPATIO 110.00 SF
G.A.RA+ YWCARPO RT 471.,% SE
a
ESTIMATED COST OF CONSTRUCTION
130,04.60
PERMIT FEE SUMMARY
CONSTRUCTION FEE 101-000419-000 $7,19.00
E LAN• CRECK FE1 101-000-4-39-318 $618,74
1VIEC NA1+lt4 AL't 101=000.421•-000 100.00
ELECT RiCA1. FEE* 101«000-420-000 $134.92
PLIMBING FEiEZ 101-000-4.19-000 $144.75
STRONOMOTIONFEE R.31D 101-000-241--000 $13.02
GRADING FEE 10.1-000=423-000. $20.01)
INk32.r4„S'i'RUC`1'UREFEE 225-000-421"1.342 �2,89S.ga
ART i1,4 PUBLIC PLACES - P.FSfC 701-000-255-400
SUS -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID Ci:ES
$0.00''
'TOTA%.:E'�IaiV6 T P'EL.S DUE NOW
94, �t16.3t3
RECEIPT
DATE
BY
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
-ld —
Combustion Air
Roof Deck
— —
Exhaust Fans
O.K to Wrap3
_ 16—
F.A.U.
Framing
,j— —
Compressor
Insulation
— Q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
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 Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas•Test
7/
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: