9909-087 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that G am licensed: under provisions of
Chapter 9'(c6mmencing with Section 7000) of Division 3 -of the Business and
Professionals Code, and my License is in full force and effect.,
Licenser Lic. Class Exp. Date
1391�t3: IOf31i19!
6at� 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).
O 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 fog by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued:
(,K 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:
Carver Policy No. '
GL 3NA IPIX INS,
(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
worke compensation .laws of California, and agree that if I should become
suP"ect to the workers' compensation provisions of Section 3700 of the -Labor
'?Qode, I shall forthwith comply with: those�provisionO
Date, `moi /! ' i..,Applicant n' .f , .J f . [ .•, G• .. '
( f 'el
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltles and civil fines tip lu. $100,0Q0'Jn
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 subjecYpermit 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 law's relating to the building
-onsttrucfion, .and hereby authorize representatives of this City to'enter upon }
the bove-mentioned property for inspection�plurposes. % i
S✓ ignature (Owne
r/Agent) )� '1 •"� L `""`t' Date � 1 e
-BUILDING PERMIT _ PERMITi�
DATE VALUATIONP4tb7" LOT -h. TRACT
,/
JOB SITE 4-5-390 SUNBROOK LANE,
ADDRESS
r..
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CENT' MX CROMrELL (O' e{8M'tMITIES
CG91UPLY f:ROWk'?1.,.i., CONI M1AS."4`f i s
1.535 SO. `Dj TfRVET, STk.-. 9,'j0 " .
1535 SC), "DO S'TREM',:S'"1 E. 92M
'SAN BERNARDINO CA 9
&aN 1RE.lr'I+MARDINO C, -,k 924T8
(909)311-61007 CBL# 21.20
USE OF PERMIT
SF -D- LM l:..PLAN _ 4A, - PIRtYuiii: f I'f'3ta3 NPT,NCL JDE BU?6: 9. WALT_ .
t79I..Nc3frt.. 7s' � It.'�71LYC'�'IC9N' O2� F�,I:,Aal�T C:H#.�CfC I'1c:E i�Es A�itLT'ff.'LR .
ISSURANCE Or SAME PLATS `I'y.PE.
IFK(T CONSMi,TE013 1F
JAdUMCARP\Jr Sp
w:!IT TIN ::�.�`9tfA9 4 �S� 01t+ CONST� RUCTION
11 �.C, i ti3i.ffi�
PERMIT FEE, SuMhURY
c:�N��rlae.���`arsrr, i:tll��il.Te-4iIs�ifi�' &i•��.fN,�
PLAN CHECK FFM 51,44:' 30
$47100
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.
Pl,(ilytt3lfV a F 10 OUt�• i3: b:f 4 ;5
VROAtGMOTlON58fi- SM 101-000-241-000 SIAM
GRAVINGT`. it13.-1' idr. 3-t1t3 V20.00
ART LN :PIN3LIC PLACES - 1:%9SMr .014=-255.000
S.
SUR-TOTfid, CX_)11;'s�MJ(.1'101X JND ALAN CHECK
43,132.36
LESS 'PR&RAI.013FES
$0.00
RECEIPT
DATE
BY
DATE FALES
INSPECTOR
�(
,
V; f
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION "
DATE
INSPECTOR
BUILDING
APPROVALS
'MECHANICAL APPROVALS
Set Backs
Forms & Footings
/� Z 7
Underground Ducts
Ducts
Slab Grade
2 - -Lg G' _
Return Air
Steel
Combustion Air
Roof Deck
12 •3 t3', i
Exhaust Fans
O.K. to Wrap
F..A.U.
Framing
— 3 `�C� !S
Compressor
Insulation
/
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
"ice
Drywall - Int. Lath
Final
Final
4 =7 -
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location .
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Waste Lines _ �� �/
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
1-7-4-60 .%4 9
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)�S-
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)