9909-085 (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 Busine'ss and
Professionals Code, and my License is in full force and, effect.
LicenseLic. Class Exp. Date
I.188 B t0131f19! -
r` f,
ate�//,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).
( ) 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 for by Section' 3700 of the Labor'C.ode, for the
performance of the work for which this permit is•issued.
( 1 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:
No
Policy ..1
Carrier C►O'E1I�IrCaL1 tfyyr, 54*S0
(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
C de, I shall forth,w,ith comply with.those provisions.
ate: '! Applicant r� / A
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'tiuilding
I and hereby authorize representatives of this City to enter upon
the above-mentioned property.,for inspection purposes. .
, ignature (Owner/Agent) � bate
—
BUILDINGPERMIT PERMITI1�n� T-.
�r 3
$871,
DATE VALUATION 374)10 LOT TRACT
JOB SITE 45-430 SiJi` BROOK:.ANE
APN if4d'�3440-01115
ADDRESS
OWNER
CONTRACTOR [DESIGNER/ ENGINEER
CENIURYC:1.',.ONVEL L COMPa' UNIffIE8
CEIVI'iJRY tOROVi ELL COM1V8'C>NQ' LES
1.:.533 S0. "Li'..$TR.l: ZTV SM 9.2,00
15.3 SO. "D" S'1'1.R,W1',• '1'. ##200
S,./`1N BERNARDINO CA 92408
SAN 331 RNAtIDI €O CA 92.108
(9V)381_kJ007 `BL#t 2.120
USE OF PERMIT
.S1NGL,l FAMILY DWELLING
3. PLAN'2A, - FIAM-IrIAlk1L4 3 NtYi, INCI 1111Xv tcYA }, t3Pi •'.
PLK).L. 7500 RMIC1710N 014 P1. AN CHECK i M OR ikR,t>LTIPLE "ISSU ANCP
OF SAME PLAN TYPE.
dARAGJVC A.RP0R? 413.00 8
t
ES TIMA' ED 0081'01F COIN15 UC TION
87,372.80
PERMIT FEE SUMMARY
CO',%T1Z13'G'I'i0H,M 101.,000-418-M $5Ps5. E3
PIL.kN CHECK FTE 101-W-439-318
IHIEC44A1`WAL FES 101-00042.1-000
I.ISC 11ZXC.a�Jt. F0, 113'9.- I? -4 0 Q9Q 1<d07,
3�x[JiMIs INC3 ," 1011-000»4'14-W0 $128.75
STRONO MOTION F FE - ?'fl 101-000-24140
Cry. DWO PTE J01 -000-423-0W_ - 320.00
09?JOLO 'ER -f IVl TACT 1""1:-i $.i,yO�AiII
• 4l
SUB -TOTAL CONFI"R1.)CTIOrJ•,tlND:P.Lt N CU=
$2,927.24
-LESS RKE-VAILYMS
$0.00
'EI'ota Mawr rElLs DUE NOW
92,9X1.24
RE'CEIP,T
DATE
By
D FINALE
INSPECTOR
IV I V
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
`� q�
7�/
Underground Ducts
Ducts
Slab Grade
2
Return Air
Steel
Combustion Air
Roof Deck
17- - 3Q _ i
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
— 1— pp /!�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party.Wall Firewall
Exterior Lath
Z —cl - Q
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
I I
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
i rZIP —00 of a
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
_ 2 -tip
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
Utility Notice (Perm) S� c 61,06