9905-211 (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 Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
09W,15 E;
Pate t'` 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 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. 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 and will maintain workers' compensation insurance, as required by
Se�otion 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.
`NI) 1035-;3.4 DC7
(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 those'provisrons'_
✓bate: i 1, rH �t. Applicant f •
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the. Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for' a permit subject to' the conditions and restrictions set forth on his
application.
1.'Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of _La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of.,such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, 'and hereby authorize representaUyes of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ` Date
%) %U
BUIL DING PERMIT PERMIT {J
DATE _ f f VALUATION LOT 20 TRACT
S2 14,9
'�'
JOB SITE•
y
ADDRESS %+610 8P GLA&% HILL DRIVE
APN
7694 50-08
OWNER
CONTRACTOR/DESIGNER/ENGINEER
r10 BOX 81i1 ...
1425E trNi ; E Si I'tg ss"3�t N`
i;.A t',71'JtNTA. CA. '922,53
1?I40FW1,X AZ 85014
( it2i257•-l�S4i 081,4 4990
USE OF PERMIT
�+iRGLE FAMILY 13i�f1?1.1n11v`
>'
SFJ) . PLAN 3A, WT 20. • PERM1T.liOE,$ NOT INCtUD11 1.3i.E'. MWA LS
OR POOL. PLAN C .MC'K POW ION QV E1. ltO)UCWh 0.75% FOR rV1L(Vf111L1?
1:0031JANCH 10F SAME P:LAN'1'3'PU.
CUS704vi. CONS'ittUCT:rir N 2610.00 JF
Pf3RCHAIIATIO 140.00 V
GA1dAt3VJC'AktT•'0XY 4%A 317
.i':+Ay1�AX1�.1Atlb.f D�l.V'S ,E 011 CVa{S1J.14.ICTIO`�
214,1941A,
;q��p
YY ��gg��Ay�,g¢'yy�yy ��n� yy�,SUMMARY
CO ST•1i13CT1ONFmoi 101-000-418-000 $1.042.00
PIAN CI'• PC;K FNS 10.1-WO.439.31 $214.03
(:1,3ANI 4, FIX, 101--000421-M 5105.00
E.LEC'1'fUb:111. FEE 1111-%110-420-M $ 158.8.1
P1,UN. 4BTN(J M 1 �)1-000-41 Q-CVQD S I80, 5t)
,3'[`€ O-140 MO'I ON Fff, •' R.SID I01-110-241 -OW X21.40
r.1tA1 NIG FEE 101-000-423-000 5211.016
INFRA STRUCi"(Aa;. V U 225 443.1542 SM94.30
.ART IN PUBLIC PL. NC FS - RESW '101-000-25.5-000 3287.35
SWI-IWAL COM7,111,1JGMON AND PLAN C'MECK
Yj,873.48
LESS PRE-Pi"M FEES
$0.00
TOTAL :k'FAM1!:T F IEWi A)VE NOW
S6,823.48
RECEIPT
DATE
BY ��(r
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
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 _ ti
Exterior Lath
Drywall - Int. Lath _
Final
Final — -
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
e
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)