9909-077 (SFD)LICENSED CONTRACTOR. DECLARATION ' .
I herebv affirm under venalty of periury 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 ltLi . Class Exp. D a��J1 1't19�
II J i 4J
t/ate Signature of Contractor �'
ioi
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that-1'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 in 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 Code, for the
performance of the work for which this permit is. issued.
(�tf 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: Myworkers' compensation insurance carrier & -policy no. are:
Carrier GO.L.D3ENEAOLEIN.S. Policy No.. NWQ 54466PAI
(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
Y
'ect to the workers' compensation provisions of Section 3700 of the•L'abor
e, I shall forthwith comply with those-provlslonse: Applicant—'/� fy��:i✓.�I
.�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties --and civil fines up to $100,000', in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject. to .the conditions and restrictions set forth on his
application.
1. Each person upon -whose behalf this application is made & each person at
whose request and forwhose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to; & shall, indemnify
& hold harmless the City of La Quinta; its officers, agents' -and employees.
2. Any permit ig"sued as a result. of this application becomes null and void'if
Work is not commenced within 180 days from date of issuance of such
permit, or, cessation of work for 180.days will subject permit to cancellation.
I certi?that I have read this application and state that the above information is
correct. I agree to comply -with all City, and State laws relating to the building
c- r struction, and hereby authorize representatives of this City to enter upon "
tt e above-mentioned property for inspection purposes.
"Signature (Owner/Agent) ° Date
BUILDING PERP PERMIT 11119-077
S TRACT
DATE VALUATION LOT
JOB SITE 4.% 4�1L lD$ :��9�1 ..' .f.9A ; s
APN 604-040-016
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY CltOWELL. COdvtNM IU.S
CE91..1,T .'Y' CRCt°J4TIL C;OMMtiNf.'I ES
SPAN £ERNNA.3iDiNO CA rNIN
SAN DE-RN:E RDINO CK 92411E
CBL# 2120
' J
USE OF PERMIT
SH.3- LUT xn. PLAN MscR, PhIM, T uut%a .N 'a' . UJUk c k:Y-L WlkL.....
OR ;4'00L. 5%, r" UC: ION 0114.PLAN CHECK FEES OR MUTINY-,
13..31MA17Ct OF SAMEP'L.A3+II': VPE.
'rRA(;r t✓C~iNSTRL+cT10N a:4 s�r►.s� ',a
CrAi3,d5,GWARPORT 416A 9F
ESTIMATE 1) COST OF CONS71'Rit4 ION
116.753.64
PERAUT FEE SltiNWARV
CONST3 UC.31nONTEC M«00"M0(0
PLAN CHECK FI lt3 a-�sa1-�t39-SIR 5144 M
;1fCCtdf+' °IrAY, I" �{�S:-OO�t-�4 ,t -e rKJ S47.0
Ei.Et:NMIC.Af FEE 1�1-*�itIQ-92Il�iti� �R:�a.£12
P1.Dtl4€C3'Cf+GCi'� 101, 40419-000 S 1.N.75;
.� t NCi Wit) f fLTt�i FES^. >�IaSiD) 01 -000- -lr'�)t� $11.60
��"D''�$QJ13I..TC YT.,yf'ES - IILi�'DD,: aD)l.-i.1UQ-2S��d100 I.Sf3
f,.r
SilrRIXY ALL, CONSTRUCUL7N AND PLAN OJECI%
L= PRE -PAM FEES
$0,00
A
RECEIPT
DATEBYt
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ ��j
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
il t • n3 - 00
Exhaust Fans
O.K. to Wrap
P _ —aa or• [,I-
F.A.U.
Framing
�,-ly --00 if q
Compressor
Insulation
Z- Z - 00 ki
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'1, - I
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�i L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
��9
/
Pool Cover
Encapsulation
Gas Piping
Gas Test
Z
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 Q 13 O
Utility Notice (Perm) `3• tet ,00
COMMENTS: