0006-295 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of`
11-- esChapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 w Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class Exp. Date
4 04 13 r' T3012C
Z � ate' �l^ f��Si nature of Contractor fv'
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J U C> OWNER -BUILDER DECLARATION
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W W 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason: k,
Z_ ( ) I, as owner of the property, or my employees with wages as their sole"
compensation, will do the work, and the structure is not intendedcor 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).
C0 () I am exempt under Section , B&P.C. for this reason
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N Date Signature of Owner
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U Q WORKER'S COMPENSATION DECLARATION
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C:, :EZ I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
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Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
cb ? Carrier UNITED PACIFIC INS Policy No.
aoNWA 1191345,00
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J (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
3subject to the workers' compensation`•provisions of Sgction 3700 of the Labor
Code, 1§h II ff wi h comply witty!those pJb� s. /.
Date: ,!1 N`t%' �i/�j Applicant/'� ,.itccc...xxxr
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
r of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for'whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
79.Q., & hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• coXect. I agree to comply with all City, and State laws relating to the building
cppnstruction, and hereby authorize representatives of this City to enter upon
fie above-mentioned proppe�y for inspection purposes.
Signature (Owner/Agent)./$+ Date�='&�6
I=
BUILDING PERMIT PERMITN
DATE VALUATION LOT _ ` - TRACT
$271,035.10 1 29347
JOB SITE
APN
ADDRESS r--5ar,.,.7 7jg3 _WA,Y•
767-330-M
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SmWN WALXER HOMO
SrEM'vVI,AL.Wn HO)aS
7161 INDIANA. AV,4•.+
7141 INDIANA A'4
RIVER.S.WE CA 92504
RIt EUME CA 923W
(909)784.0840. CIA" 5357
USE OF PERMIT
SS1JGI E lFAMII Y Db'VR'•T..d.1NO
Cdr
SYD• LOT 31 PLAN 3A PER -MIT DOES NOT INCLUDE BLOCK. WAIJZ OR
POOL
CUSTOM CONSTRUCTION 3,192.00 SF
PORCWPATIO 371.00 SF
GARAGEICARPORT (SP) 17,444.00
FS'1Z1&AT" COST OF C0ML"1'1ZiFC77f.O,N
271,035.10
PERWC FEE WhWARY
CONSTRUCTION F ZE 101-000.418"000 $1,241.50
PLAN CHECK FEE 101-900-439-318 $1,000.62
MECHANICAL FEE 101-000.421.000 $92.00
ZL.lX: fRJCAL FEE 101-000-420-000 $236.02
PLUMBING FEE 101.000-419.000 $169,75
STRONG MOTION FEE - RNID 101-000-241-00 $37.10
ORADINO FEE 101.000-423.000 S200
DEVELOPER IMPACT FRE $1,907.00
.ART IN PUBLIC PL&CES - RESIt 701 0004255.000 S177=59
STIR -TO AL. CON:t UC` ION AWD I'1,AN CHECK
$4,845.58
LMS PRE -PAW Ins
$0.00
'TMAL >;=.t'R?Aff TYM DOE NOW
$4,845.%
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RECEIPT
DATE
BY /
DATE FI AL
IN
P OR
t
It
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
--jam �o
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
Vents
Fireplace P..
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D II - Int. Lath
lb
Final
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 Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
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 Q
Final
Utility Notice (Perm)
Final —
COMMENTS:
�1 / _ 76 _ Pt/"
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