9909-079 (SFD)LICENSED'CONTRACTOR DECLARATION
1 -hereby affirm -under penalty of_ perjury -that.) am. licensed under. provisions of
f
Chapter 9 (commencing with Section 7000) oDivision 3 of the Business and
Professionals Code, and my License'is in full force and effect.
se
LicenLic. Class Exp. Date
y I�I&'S B' 14lI"3IJl��!
�.te Signature of Contractor'��A�''
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 myemployees 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).
() 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.
(,X) 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 Af3Li: 91�TS. Policy No. - fe��3�C�5�IM684)).
(This section need not be' completed if the permit valuation, is for $100.00 or less).
O 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
work rs compensation laws of California, and agree that if I should become
sug)ect to the workers' compensation provisions of Section 3700 of -the. Labor
, Ede, I s all forthwith comply with -these provisions:
rDate:
T" / 'iApplicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,. in
addition to the cost of compensation, damages as'.provided for in,Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a' permit subject. to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this, application is made & each person at-,
whose.request and for whose,benefit work is performed under or pursuant to
any permit issued.as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and. employees.
2. Any permit issued'as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectiooh purposes.. /
/Signature (Owner/Agent)`—x� -,bat ' !71X
BUILDING,yP[�EMtRg���M,[�iIT PERMITS _ T
//
DATE VALUATION JI+Y9Jw7uV•vvis. LOT, TRACT ,2399.5"7
JOB SITE�:?^�/� difl�'fik�}rRK,Ai�$Su d,rAIV.1�,Yr - ...
APN}'�-�r•-�.r'I'�/
ADDRESS
.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CUMMY CROWELL COMMUNITIES
CEN'➢URY CILOWET.L CU`,?�tMUNi7' ES
I535 SO. -.j.)A 4iRM, STE. 42,00.. ':.::
1535 SO. "D' STR.ET-N, VE,' -42(0
AYE' BERNARDIN O "'CA 92403
SANd BE�ftNARDINO ; CA
(869)3 I„106i CBL# 2120
USE OF PERMIT
SINGLE FAMILY ONVEi.A INCA
, .�.q3' tip .: tai 11” I CI Ok( 6In.�:4rf,'y��5:.-'� A).,L
1ilpAtTifdt
yS,!<IDLi-f, ♦�CeYsI` f4►, gSUBI
t�S¢��14
OR .PGJ�..L. 75% 1 91DUC.n i4.)N ONN, AN �,IiY� C.K J!'.L:� �./�..i�'�.. L IPLE
ISSU.11ik CE OF SAME PLAN TYPF_
'+rt'EACT C0'NS'4`IE VC110,N'' ZOOO.00 3
GAYCNOWCANNIRT 416.00 SW
ESTIMAIM'D CREYST UP CONSTRUCTION
116,-'s3160.
PEI RMI •3i* EE SUMMARY
CONSTRUCTION FEE II3.I-(i@II-�I8-oon SS�9.00
PLAN SCK FJFX3 1.01-00439-3I8 $.14•t.��
W)CHAMCALYMM $47.00
ELECTRICFEC $ 126.82
PIARVIBINGMM, t'�iI-(h7a• I9•(tltt� R1 �.7
S TRONG:fUl'OTION*tF.E' - RE SM 101-000-241-000 $11.6$
GRAMM FFA 5n.00
DEVELOPM MIPACT FEE $1,90,00
ART w rtamic'I tAcx's , Rh— a r 701-000-25r5-000.-
Si1E�-'f'CYI ,. CONSTRUCTION AND 'l X11 C HEC':IC
3 8 32.36
SS P UD 17BI7
5idgTf)►L I{'°EMUMFES',. DxTENOW
:��d►�.:1�✓:�
tr'�•
''•
RECEIPT
it
DATE 3
BY x
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MEC.H.AACAL APPROVALS
Set Backs
Forms & Footings
� —467`�/ r
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
I'L
Exhaust Fans
O.K. to Wrap
t - -er K 94
F.A.U.
Framing
-, -1 y.Q®
Compressor
Insulation
t--„4' .-rte tA-c�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
1 -I
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
_
�lp�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
oe
Pool Cover
Encapsulation
Gas Piping
Gas Test
�2
Appliances
Final
COMMENTS:
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 i - ®0
Utility Notice (Perm) 15,. 1 1 •