9909-074 (SFD)LICENSED CONTRACTOR DECLARATION
I hPrPhy affirm under penalty 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 # Lic. Class Exp. Date
f' 10131119'
Date d f r 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. 7044, Business & Professionals Code).
( ) 1, 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 QOLDF,XFEAGLE- INS,, .Policy No: YdWC 54'43.01
(This section need not be completed if. the permit valuation -is for $100.00 or less).
() I certify that in the performance -6f -the work for which'this,permit is issued,
I shall not employ any person in any manner so as to become subject to the,
work fs' compensation laws of California,,and agree that if I should become
sub•'ect to the workers' compensation provisions of ,Section 3700 of the Labor
Cce, I shall forthwith comply with those provisions.
ate:jApplicant
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 forthRon 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, br 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, and hereby authorize representatives of this City to enter upon
the 'above mentioned property forinspection purposes.
gnat(Owner/Agent) i �- I .ta l Date
PERMIT #
BUILDING PERMIT 9909-074
DATE VALUATION $116,i7$3.60 LOT 25 TRACT - 23995-7
JOB SITE 143416 SifsNBROOK LANE
APN 604-04"16
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CENTURY C,,IEa�O�pb\�I�E�vL�+L C�ONINIUNMES
CENT€ RLY i.:�iLv�yTyq��iy?±:G��L�tw47tg7�:�+ittr49.€�UN£Y'€ES
1535 S�./. flW al?li4.C� d� Swl E. S 200
1.53$ SO. "DI 171 W , STE., 1f' 00
SAN BERNAILDINO CA •9'2409
SAN BERN R DINO ClA. 42408
+' Ny-481.6wf CALk 2120
USE OF PERMIT -
S:INGL E FAIU[IL Y MEL;LIN
SFO- LOQ' '25, LAht JOAR, - . M1`iE' 00ES NOT INCi.faaW BL t e iVA�,L ..
OR POOL.
'GRAXrr CbNS'r`XUCT1ON sF'
C' �AitAGWCALWOT4T 41.6:01 SF
'EISMR'at.T D COST OfTMNSTRITCTION
116r70.60.
PERMIT FEE SIVIMMARY
CONSTRUCTION FEE 101400-418-000 $599,60
PLAVI CII'VC � '� 101-M-4139-•318
NIVAMM1C.AL M 101-M-421-000 $47.00
;iw7..EC;MCAL FEE 512602
PL.t714i81f fO FEE, 5134,75
STRONG 'la OTION FM - RESID .10.1-000-241-000 Iik1.60
GRABITNGa FHE 101-000-4D-000 $20.00
DVIELOPER YVWAC";< FFE $1,90' .00
AWf I PUIB 1C° PL ACVS - f+E%M 701- 255 -tom
• � �` fit
S€ B-"1'I:A'[ L C,`t NSMUa`"`I:LON AND PLAN CHH- K
$3,,%5.06
LESS W&PAIDIMISY�l.i2�t
a.
TOTAL MkMIT FTE5 DUE NOW
&1,56.1°5.06
a
,
RECEIPT
DATE
DATE FINALED
INSPECTOR
A
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I / 2�%i
Forms & Footings /-64+—
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck I -L -
Exhaust Fans
O.K. to Wrap - l -pp KW
F.A.U.
Framing 12 - + f -40 !{
Compressor
Insulation -L-1-3 - 00
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Z - P "y 00
Drywall - Int. Lath _60
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines /Q--
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _
Sewer Connection �'l0—�g
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 • bl -ate
Utility Notice (Perm)
COMMENTS: