9909-083 (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.
License Lic. Class Exp. Date
14188
'Date Signatu.re of Contractor
Vi
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).
() 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.,
( jdj I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performahce of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierGOLDEN F-AC41F IN,�i. Policy No. y`�C _�0�4tf3-fll. .
(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
workers' compensation laws of California,.and agree that if I should become
P
bto the workers' compensation provisions of Section 3700 of the Labor
de, I shall fort (vith comply with those provision7te: `'�
T Applicant �' % s `
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.. r
any permit issued as a result of this applicaton agrees to, & shall, indemnify4 `
& 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 3gr'ee to comply with all City, and State laws relating to the building
constry.¢tion, and hereby authorize representatives of this City to enter upon
the aRve-mentioned property for inspection purposes.
Ignature (Owner/Agent) Date
BUILDING PERMIT FERMIT3��i
DATE VALUATION $"13 1-" LOT TRACT a� �
DATE.,/
' 7/14
JOB SITE Xj[�CD
470 SIUNBOK LANE.
ADDRESS_
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CFRr4I.IffiY t'✓l ONVELL;::OMMUNITIES
CWfURY CROWEU.t f CDM,NIMIFi' ES
ASO. °T )3 :ST -Rh -.ET, STS. #2C',�f
1�535 SO., "D" ;S' F'12FET,S'A'E: 02,00
.SAN 13ERAd.ARDiNO CJS.. 9`2408
SAN BERNA.i DINO:: CA 92,409
i�ti9J 8i }.t?t17 CBL.# 2120
USE -OF PERMIT
SINGLE FAA4.ILX DWELLING
NG
SFD- LOI~ 5, PLAN )A. - PI:RMI..T SYS NG ° .iNCLi1G.E-I3f: OC -K I.V-A .I. rJR
POOL7.V4 RMUCTION ON PLAN 00CK 1 EE -OR, f%4ULTtPi E ISf'>ti AI4C ,
01 S.ni M PLAN TYPE.
TRA -C` C(J"NMUC'I7iON 1.679.00 8F
L'a•A AGOCARP+.JRT 417.00S F
ESTIMATED CV8T OF CONSTRUC'n.ON
99,342.90
PERAHT FEE SUMMARY
C-0N'.f'TRUf,"'.(`ION FEEls�i-691111-4.i8-ix9t1 ' $fi�i�:�fi
PLAN Cl tfiCK FIM 101-000-439-31.9
MECHANICAL FEE 1t9I«OD.0�2i-Clat! �:T.fli)
'Ef..�C17{IYC.R;I.:kfik :1t�d-�D�+O^�2A•Ii �V.YS.6}.
mumBiNG 1i11 }AjD .9I�-00(9 $134.75
3'.R1C3 r 1(yN ,FEZ RE30) 101-00-241-000 39„93
C'IZADX3 , ]ZITE 101-000-423-000 11201,0 3
i Vae m"R fib PA q, F9
SU.8-:i0Tjx CON , t:UCTION SAND FLAN CHECK
LESS T'���-PAiU FliRa
$0.00
TOT* PFRMIT r, FXN 011F NOW
S3,00co
RECEIPT
..
DATE
BYE
DA FI E
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7Underground
Ducts
Forms & Footings
Ducts
Slab Grade
Z �— �G-J.,
Return Air
Steel
Combustion Air
Roof Deck
17, • ®. TW
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
2 --it -00
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-3-1-00
Final �d
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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
=`O -�'
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
- !o- 5a
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
T
Final
Utility Notice (Perm). I1