9909-086 (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.
Licens LLiic. Class Exp. Daje
ii
to
/ate21 ! � Signature of Contractor,f
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
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 C3�; E f LaAC/ '1148,Policy No.. NWCS440634td.
(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 Ias to become subject to the
worker compensation laws of California; and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the'Labor
C�a�i4e, I sha� forthwith comply with,those provlslons•.� Q^
ate: i✓ -Mr -'Applicant
Warning: -Failure'to secure Workers' Compensation coverage" is. unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building -and Safety
for a permit subject to the conditions. and restrictions, set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is,performed'under or.pursuant to
any permit issued as a result of -this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:•
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and state that the above information is ;
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon'
the above mentioned propr inspectpurposes. �
erty for f
.. %F� t`�
(Signature (Owner/Agent) 1 Date
BUILDING PERMIT - PERMITp����
DATE J VALUATION ��''LOT 6 TRACT ti'
JOB SIT _4541411SUNBROOKLANN a
APN 604-040-016
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ClINTILTRY CRONVt;LL CONIR4:1P 1I`I'MiS
ML'I'tAY CICttY9r;Y;ELL COMMUNMOS
1.6:33 SO. :.W 917REEF, MT, #200
' V 33IrRNARDIN O CA 92408
SAN BEItfixw RDINO COY. 992408
( 109)381-6tfiP1' CEI.ir, '?I2t3
USE OF PERMIT
SINGLE FAMILY DWELLING
WV- LUT 2,1 AN 31Wr - P ; H Uk hS M)T .I.NQtXfuL J1L(J ..sc. varJA, .
Qft2 Pte. 75% E3)uCTJoN UN vwL.AN C7d Fmk*Mris OP. 107Ji,'1'tPL,E
ISS'G'ItMCEL OF SANTE FLAN 'C''d PF
t�tR117'i{dlIA..C� F CO. NSTR13CTKA%Y ' 1.f�/i79:S0)�0 ISFI
�1AI�.•+ASu"'OR 41, .00 8F
MI TIAIA 13 4D B.:O$T OF CONMIUC110N
PC, t1;$fff PEE 18I1NIMAtR
^.Ci1vS'1'FtifC'1't{3YJF'ts'Ir "to] -000-418- ) $639.541
.PLAN (3116C& 'FM -*t 0 i-e1[e(I�3+�� 3IS3 s 132.90
N.MCHANWAL FEE 1,01-000-42.1-'000,
El.f✓C' IUCAi,. IrtR i 014XI042040
101-400-419-000 1133.73
31*R0 Q A-10Tf,0N F&- - t{RvU") 101.000,.24I-000 $9.93
OE'VL?i fJrPER IMPACT ` FEE
SM-TC,4`fi. AL CON S';C'.I'.IXI'tOR.tt ND PLAN C tffiC K
$3,006.69
LlrS.4 PR&PA II.) SEES
50.00
'jiM13,Ia PERMIT FEES DUE NOW
RECEIPT
DATE `
BY'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
. MECHANICAL APPROVALS
Set Backs/� q _
Forms & Footings /- G_
Underground Ducts
Ducts
Slab Grade - j 6 1
Return Air
Steel
Combustion Air
Roof Deck /Z - 30 •9%
Exhaust Fans
O.K. to Wrap 0--
F.A.U.
Framing
Compressor
Insulation!L,: J _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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 - Z. e0 XA.F
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 3 -'Zd na
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: