9909-084 (SFD)LICENSED. CONTRACTOR DECLARATION
I hereby affirm under penalty of perj6ry that tam licensed under provisions of
Chapter 9 (commencing With Section' 7.000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.,
License -# Lic. Class -Exp. Date
7 14188
V
f 5 �at eiek7A 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).
( ) 1, as own6r,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 pe.nAlty of 'perjury. one ,bf the following - declarations:
I have and will maintain a certificate.of consent.to self-insYre for -workers'
compensation, as -provided provided for by Section 3700 of the Labor, Code, for, the
performance of the work for which this pe�rmit,is'issuecl.
4 -
I have and. Will maintain workers'�coriio6nsation insurance, as'required by,
Section 3700 of the Labor Code, for the performance of the -work for -which this
permit is issued. My work6rs" compensation` insurance carrier &'policy -no. are:
Canier o0lDE . N . &A(" !N�, , P . o1.1cy No.
(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 1aws of California, and agree that if I should become
subject to the workers' compensation. . proVisions'o f Section 3700 of the Labor
de,
aborde,I. shall forthwith comply with those
Rrov
IS11112 IS
Date:4�2/ k12 Applicants
17
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 applicator 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
Zthe b6v'e-mentioned property for inspection purposes.
ure (Owner/Agent) . Yq C—t Z"X-t) — Datte
BUILDING PERMIT PERMIT090V4
DATE VALUATION LOT TRACT
JOB SITES 49,450 SUNBROOK X,AXE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY ClOWELL CO&MUM MS
CENTUkY crLOWELL C<)MMUNMES
133 5 SO, "Dr` SWS U, IR2 0 0
15531SS6 11Y SMEFT,1STF. 9200
SAN BERNARDINO CA 92408
SAN BERNARDINO CK 92408
(901pst-6007 CBIA 2120
USE OF PERMIT
SINGLEFA MILY DWELLING
6 31, V- flu FEFW01T VU10S NVY INCLIAM ULULX, WALI
OWIPOOL. 75% IZEMMON 01q ' PLAN C' K, FFE ORAVILML16,
ISSUTULNCE Or SAAMPIAN TITE.
MoLcr CONSMLIC'InON 2.000,00 SF
GAMWCARPORT 416.00 SF
ESUMATI&I 1) cosrr OF CONSTRUCTION
114, 751.60
PERMIrf F ZE SUMMARY
CON' STRUC71ON FEE 401-000-418-00
PLAN- CHECK FEE 101400-439-319 5144,13
W,CHANICAY-FIRT, $47.00
MXCTRI(C.I%L FUR 10144042040
PI'mmm No Am $134.75
STROViTMOTION FEE I
CYRADIFNG M
DEVIELOPM 1fvff-ACT- FEE
AR REMI -7 918 .,r IN PTIBLIC PLAC23 - L ,000-25-540 541.9
SUB-TUDAL C0N$T&1:i(-11CrN M.0 PLkN CHECK
i. S'P19jri-PA1D.,VT1t.110
$0.00,
TOTMk PERMUFFES.DJUENOA
RECEIPT
DATE
BYINSPECTOR
DATE FINALE
61
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
/,!
/ �j
Underground Ducts
Ducts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
t,- 31 -.no t
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 -e
Drywall - Int. Lath
• 2 -6t®
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
O.K. for Finish Plaster
Sewer Lateral
., Z (p- 00 j
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
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)