9909-076 (SFD)LICENSEDCONTRACTOR 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.
Lidense.J1:#� s� Lia Class Exp. Daletir�lf �
ate. �jA Signature of Contractor�f d •!°��
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that'l am exempt. from the Contractor's
License Law for the following' reason:
as owner of the property, or my employees with wages as their, sole
compensation, will do the work, and the structure is not intended oroffered 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:
O 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.
( ) 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 Ct�MEN EAGLE, MS, Policy 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 anyiperson in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subjg'ct to the workers' compensation provisions of Section 3700 of the Labor
C de, I shall forthwith comply wilt those provisions.
t ate: 1 /?l� Applicant ��;1'
Warnirig: Failure to secure Workers' Compensation: coverage is unlawful and
shall subject'an employer to criminal penalties and civil fines up to.$1 00,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest,and attorney's fees.
IMPORTANT Application is hereby made, to the Director of Building and Safety
for a permit .subject to the, conditions and restrictions set forth. on . his
application.
1. Each person, upon whose behalf this application is made & each person at
whose request and for.whose benefit works performed under or pursuant,to
any permit issued as a result of this appl'icaton agrees to, & shall;. indemnify,
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued, as a result of this application becomes.null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work, for 180 days will -subject permit to cancellation.
I certify that I have read this application and state that the above information is '
correct. I agree to comply with. all City, and State'laws'relating to, the building
,construction rand hereby authorize representatives of -this City to enter upon
the above-mentioned property foi inspection purposes.
s nature (Owner/Agent)'�1 • :_' vz•��- % Date f )Y5
BUILDING PRMIT PERMITII�����v��
21945-7
's93 .3"i'4 t 27
DATE VALUATION LOT TRACT ,
JOB SITE .� i Ds .
APN 61 -•41I-0,16
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CENTURY CROWELL COMld%[J.N6"d'i�. S
Cw1'l: p y CRO"WE I; CC9MA2UNITIIrS
153 . "TY- 'TrRE T, .�.ti" :# G0
1535 SO. "rY !�1`R i E` r, ;QTR. 200
SAN € ERNAT'1AJ'iS^YV CA !MIN
AAfii ,SERNAELDINO STA 92408
CR1.4 2120
USE'OF PERMIT
3t1 NC31X F.A1 flL Y DWEL fNG
- `�
'3. --�
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t✓ ..lr C., dSGS,, - ' �3t31 1, C'i�l�"� kA 1. .1W l.�_ Vi. �
'!RAC T CONST3�.:UC' 10...14
a'ARAGEICARPORT .413.40 SF
�• ;�7p 1}•�{ 3.'@.+NxI 'b+'�7S7TY v,l.N���YYI.VA7..i 9RW110
PERMIT FXE SUMMARY
CONSTR1,3MONFEE
FLAN CHEG7(+;. FFi1'i, 11.01-000.439-31$ �RS1.5a
W,'t'.HANICAY FEE �f9.Y iiij6} ?42,1.4 �fi7,44
FbY. i n -f i k42ti�t3aJ4D ia7.d3S
r �.I.�'Arf.T�[Nt:Tr E"CsF..• .. triiY-Q(�{)•�4:1�}^( $128.y�
S'>i KONO MOTION FES S8.74
LINO FER
'DE'1ELOPER IUMPAC'1'tu'lslW' .$1';f 7.00
SO-8-TCT:"110 CON Sw.A�RliVM01N,AND .CLAIS1 C.Ri:4.,K
`®33294.3'
RECEIPT
DATE
DATE AL
6ZIlDn -
INSPECTOR
- .7
a
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
/ l;;! � c�
( Y' (
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K.toWrap Sgg lE»,yY12�3S
�" -CCJ &4
F.A.U.
Framing
Z_ I &L-Aj)
Compressor
Insulation
Z - -12=00
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 _ l -L , CO
Drywall - Int. Lath
Final
Final
-"t
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
_ i
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
T/b
Pool Cover
Encapsulation
Gas Piping
Gas Test
$j • 2
Appliances
Final
COMMENTS:
1,La,-r t
SE Ira ` Q b.� s (.a o, v- Z - / S -ivo k
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 6. _
Utility Notice {Perm) g' • t q •gyp