9909-081 (SFD)LICENSED CONTRACTOR DECLARATION
I herebv 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.
LicenseLic. Class Exp. Dat
.e
�1d188 B Ib/31i19�
vb/ate , / �` 4Z 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. 7b44, 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.
(�) 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 C7C�l `iE1v.F Policy No. NWC 54406&01.'
(This section,need not be completed if. the permit. valuation is. for $1,00.00 or less).
() I certify that•in the performance of the work for which this permit is issued',
I shall not Mploy, any person in any manner so as to become subject to the
worker ' compensation law.s'of California, and agree that if I should become
sub' ct to the'workers' compensation provisions of Se*ctiop 3700 of the Labor
C • de, I, ell forthwith comply with -those, provisions r '
I ate: Applicant—l ,/ r /�/ AZO
Warning: Failure to secure Workers' Compensation coverage;is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interesf.and attorney's fees.
IMPORTANT Application is hereby made. to•the Director of Building and Safety
for a .permit subject to the conditions and restrictions set forth on his
application. -
1. Each person upon whose'behalf this application is made & each person at
whose request and for whose benefit work is. performed under or. pursuant'to
any. permit issued as 'a result of this applicator agrees to, & shall, indemnify.
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null'and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days.will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. l.agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspection purposes.
Date ) ° ; % ,%
t8ignature (Owner/Agent) { l✓ .
BUILDING PERMIT PERMIT j/,'a
///
DATE / VALUATION LOT ��' LOT 7 TRACT 2WS-7
JOB SITE 45-4.I10•113;i1WO'RfZOK IANE
APN 69$"40-1016
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CEN'TIMN Cl tSi'U'rML GOMMLTN1'T`FES
C.EITWRY CR ME -X,<1.; CO14X113.f:iMES
1 �+3a 5�3. rr�rr 4`�°°'tt�>��,�E.. �i�fs� • :
i.5� �Y7. �"�"' S'1'Iirr:�':1',' � T'�. 'ia'Ztif1
SAN'f3.EANAMNO CA 92408
S.AN BERRARDINO CA 9 R
C81.# 2120
USE OF PERMIT
SITNIGLE FAIVITLY DaWLi, IN
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v �ro v >:< .:t L�. r'.
POOL. 7594 RMUCT.1'ON.f.14 PLA14 Clic-M i^'M OR }\..LTI TI[Pd.,E Y;3i,$0%-iEJt"I�-
OF SAP&PLAN 'Y'1'3?F
TRA( -',r CO'NS'TRUCTION 1,460.00 SF
GABA 3 YCARPO33T 41160 SP
F,;SUMA` ED COSr Ort CONSTRUCTION 87,37.84)
Y'ERMr5 FEE *SiME9rtARV
CONSTRUCTION N FrIS, f O I'X00-4,18-E?tiQ ' - SM5.50
PLAN CMCK FM 101-000-439-315 $122,39
SuiE�'1tA3�T1CAL1'Y�? ' 101-DdTfi-4 1-tit)RJ 547M,
ELECTRICAL i"f'E t. ►Y�ft4bfl-d��a-Crfi� �;Et3�;1zfi
KL11AMIN 0. FEE 101-t" 00-47;19.10M Bl." . ,73
STRONG M0170N ME - ,F.E3r D 101-000141-000 .18.74
GRADDIGRE,t0,1,-fsrZl(Y A; Q170 524100
I3Fs'b'E.[.(7P:Et..R IkeI.!4!".:"3" .t' M 1.1.907.00
_
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<y;
�+q p,� 1 +�q.. t / `p -yet..
�T g7p�6 PLAN
' ,J4JE?"' 3 �'Y A�I,r \i'O1.'9 e�.�L 3\U .�L ON .Ax9.R/ .P.ijaAN C37S:t,. K $2,927,24
CHECK
LESS PR&PAIL)TEES $0.00
Ti3't . ".mirMIT FEES. Dur Ni3w $2,927.24
E
RECEIPT
DATE
BY
DA FI ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
'MECHANICAL APPROVALS
Set Backs
Forms & Footings`
/
Underground Ducts
Ducts
Slab Grade
/2 3- gy
4,ie_
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
`_ t
K
F.A.U.
Framing
Compressor
Insulation
— ft -60
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 — —Qp144
Drywall - Int. Lath
_ (—
Final�d D�
Final
POOLS -SPAS
BLOCKWALI.
APPROVALS
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
Waste Lines�� -
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
z/`�
]r
Pool Cover
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) 101