9909-082 (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•#.1at� Lic. Class Exp. Datg;,. M9,
/�!!' t3 � F AiHJ
ate� �w Signature of Contractors"�L�
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). '
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 4. B&P.C: for this reason
DateSignature of. Owner
WORKER'S COMPENSATION DECLARATION
I hereby 'affirm under penalty of perjury one of the following declarations:
O 1 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.
(X) .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 Policy No.
C90f�DEAi E4 5.:. N WC, 34106"1
(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
subject to the workers' compensation provisions of Section* 3700 of the. Labor
de, I shall forthwith comply with thosejp_.r6visions'3 j
ate: Applicant-
Warning:
pplicant 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 applicaton 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 complywith all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
t,Stgnature (Owner/Agent) `�"�'�• Date fl /
PERMIT PERMIT9�, . _
..BUILDI"NG
'111�(1.�"'7i
DATE VALUATION'` 'y ! "LOT TRACT
JOB SI ii }�} 1 !(� ,
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CrNTLJR.Y CROWELL C.;OiMN-iNMES
CE1`i'1"URY CROWELL t'0:1vf:AfMU1N1' ES
1535 SO. " Y' ST R1=, RT, S"ft.#:200
153: &Q. "MSTRE'FT S'i'd. #200
SPAN BERNARDINO 11 A 924011
.SAN BERNARDINO CA. 92.40111
(09981460(n 1-a0(n CBU1 2120
USE OF PERMIT
SING FA1t2f:i.S' .i7 E1,LING
:irt,>>.�.�r tr; p�1.tLL�s �c.:sc, - 4� I41 r .� ►ta.�:.� ets:�'f: t , t,i„ . cs. t ':5: .t. •
OR POOL. 75% "DU i'£ON ON PLAIN �"MC,`K M, OR. PofW 4'1PLE
ISSORMCE OF SAME KV1 TYPE.
TRACT CONS! #tIXTION 1.679.00 SP
GARAt1.PiCtiFtlPORT 417.00 81±
'r+ T1, Mix TED COST OF CONSTRIXTION�9s
i�� elf
PERM t' FEE StC1T+ MARY
{';c:ald:3'1 RUCN"dt3ra .FEE 101-000-418-000 $639.50
PLAN Cmra= IFFN" 101-4011.430-319
l°cBCX,', ,FR
i6LEC;TIUCAa F'fw �fi3],�dP�O-t#2 0 1st.BS.li.l
PLUTWt1NO•k£�M, 134.73
'STttOM, W447f 10N F ME - FJ38 W 1.01,000-241-000 S9.93.
.
GRADING FTX 1.01-000-;323-t�iU
VEV.011�3� IMPACT FE :... _ Sl,%7.04)
V,
S�l:�3=1'0;�4L �;()%tS"3' UL -1,100 t�N{{4q�J�y'�f.AN C�:I'1FEC:■y��:
1p
,b){b./ti}�9t
Wq
SS
9 .
TOTAL PERMIT IT FEES DUE N011V
jY ..k .
RECEI
DATE .
BY
DATE FINALED
INSPECTOR
N
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.4
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i •4t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings �`
Underground Ducts
Ducts
Slab Grade
12 3—%`l C'
Return Air
Steel
Combustion Air
Roof Deck
IZ- 38 -mil
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
t — ''if —00
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 — — 00 /
Drywall - Int. Lath
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
Waste Lines— O%3
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
C— 2 (c
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)