9910-045 (SFD) (2)LICENSED CONTRACTOR DECLARATION z
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
/ �v 1Ai42+it l i ii;i1
Dafte/. /?-� T Signature of Contractor /Z,
J OWNER -BUILDER DECLARATION,
I hereby affirm under penalty of perjury that I am exempt ftom the Contractor's
License Law for the following reason: t
( ) I, as owner of the property, or my employees with wages as their sole I,
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 i
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under.Section B&P.C. for this reason
Date Sianature 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 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 /�+•��, TM;pp ((���� Policy No.
L:.r4f�1YlY 4 .
(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 forthwith comply with�.hose provisions
spate: 21 S 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
& 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
theabove mentioned property `f,,orr i_nsp/ection purposes.
,Signature (Owner/Agent) ,� �� Date,r
�
PERMIT#
BUILDINGPERMIT. 9910-045
DATE 121?i/l,"VALUATION 5.5.17,494 >?0 LOT Y+ TRACT, 4N,470_
JOB SITE r w.. a...
ADDRESS !6-3711 �iA�i i(; IKE,II..KTU-I41'�
APN n w
!V, 6-SWO42
OWNER
CONTRACTOR / DESIGNER / ENGINEER) ?
r'i.%t'! HO":Y BIs^.rGINS
ITUDSON CONI c, r"tu -5011.+•':
35-499 OAK HILL
717-622 COUI\i"i1 Y CUM i M DR. 41,M
LA QUjWA ; CA 92253
PALM DE,,SEW f )CA 97 211
(760)34.5-5154 MN 5285
USE OF PERMIT
ti),N FAMILY DW ELL3Ntr
SC'O - NO BLOCK WALLS OR PGC L. C0-N,W.LiAR'a-; W11TH ALL r E`UEk AL
STATE LAW'd [NCLI JOINt THE 1l!.N0ANG13i3JM ACT Ui` 137:3 tib
U.S.(,-. 1531, ET S.EG►.1 (E' APPLI.LABL1,18IWQ3WRLZ.
CM03\1'CONSTRUcTI01V 4,432.00 S17
POItCI7u3°ATTO I,s:�3.00 F;
CiA6tAt; (;Aitih;r62'I' 914.00 SF'
.., SUxr W �(.�-4t"0!�•-
,CON5`IRUt.'1'LON { 1101-0)0-X418.000 $2, 153. so
PIAN ECK t+►?'.; I0I-tliN1-4314-31ft
G1?.t's10 SIT 10I-0(+"J-139`3I3-�I,�..,i;.t,J
.• � ��
&MCHAMCALja IDI -Ca -4,'x -.1 -OW S226.i)
� ,t
EIEC; C"i AL FEE 1011-000420-000 5342,40
w 4 , .► I . .
S'17tONt, &U-71TION FEE, RL"SID 101.•000-241-430-
"
ORAT?ING FERE I0I.000-42U00 32i►.iw
_" t'� 3
0EVU1,01'! R IAIPAC F 11-6,E' 8.1,9G"r.i.tt1
S.
AIRT iN Ki>it.lIC Pr.ACFl - RVS!r. 701-0060-'95540)
S t ff- -T(IrA 1. C'G)NS'1'RcX:"i10N A N 0 PI AN��(g CI 111'qC K
$7,R04,18
FEES
L.fi SS .P.1• IE -I d' ID 1' l•1•'w,l�
�/�
-$1,250.00
s4 °3fAL PERM T 107i<.:i S DIfir, NOW
it
RECEIPT
DATE
BY +
DATE FINALED
INSPECTOR ~
U
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVAL
MECHANICAL APPROVALS
Set Backs
160,
Underground Ducts
Forms & Footings
Ducts
Slab Grade
R
Return Air
Steel
Combustion Air
Roof Deck
7d9
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
a -Gt �-
Compressor
Insulation
,� - d0
Vents
Fireplace P.L.
��
Grills
Fireplace T.Q.
-!
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
D --n' Lath
Q!9
M - �+
txs
- 45- olo
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
--(gyp
Encapsulation
Gas Piping
Gas Test
l7i
Appliances
Final
Final
Utility Notice (Gas) L C! 7
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 Q• -
Utility Notice (Perm) (� .
COMMENTS:
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A-&-, ti s'-60
QC_