9909-080 (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:#. L c. Class Exp. Date
/ate��-�/,/ f'� 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).
( ) 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 -in'sure.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 GOL15EN EAGIII INS: Policy No. NtWC-- 544068-(d.
(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 permitis issued,
I shall not employ any person in any.manner so as to become subject to the
worker�eompensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
C�gde, l shall forthwith comply with_th.ose provisions.
�ate:�/ 'Q Ap' licant f ') . I✓'� 7,t'
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 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 for inspection purposes.
Signature (Owner/Agent) f � �''")!;� ��"Cc..°'� 'Date���"'~
PERMIT //s.,��
BUILDING
.PEFMT
9� r
,a' '
PATE / VALUATION LOT TRACT
JOB SITE 45-.530 3 VIN O N, tdV4 !,
` 01-00
APN 604-0401-00
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY CROWELL C(U34f@,"IFI`I:ES
C:EN'rUR.Y CROWELL t✓OMMUNl'Y`IES
1535 SO. 'T" STREET, 9rE. 4200 ...
1 _535 SO. -D" S"THET,;;;TE. #200
SAN BER.NARDINO CA �VWS
S.AN"BF.RNAtZD5f0 CA 92408
:'BL# 2120
USE OF PERMIT
SINGLE l:.lO.M1>i.:'S`' OWEL LING
__.
R._.
4.; 8,� .[ . :5 141.?1:t15,1, 7E13L4K.:& WA l,; _
OP ;POOL. 7504 iREDIX7,1 f0N ON :P.W4 CHECK ME Oft ARIL TIPLE ;
ISSURAWT OF SAME PLtAN `l" 4''1 E.
I'R.gC-T CONS'.CRUC7I-ION 1,60.00 $F
G? AKALWCA PORT 417.0 9F .
99,342.90
PERMIT FEE 8'VM1%UWY
CONSTRUCTIONFEC 101-000-418-100 U39.50
PLAN C; W- K FIM 10.1-000.439- 118 $132,90
MECHANICAL IM, 101-01;;D•-421.000 $4740
Ei<trC"!i'ft.WAL �Tig i l.l-0W-z'12i'3-ti 0 $10.61
.PL iMBING FF,k $13.9.7.3
STRONl3MO'I`IUNF E-RF,.,,t� D 301.000-24.1.-000 $9.9$.
GRADING FEE
dYf_t VELCIPEtt M1WA:CT Ff*, $i69i/7.0t)
"
x
SUB -TOTAL ("'ONS"TR FC ION AND PLAN r'.:E3ECK
LESS PW1,?-P.A1D FEW,
S0.00 .
Tn'1'FiL PERMIT FEES MUNOW
�iSy$}QP�.Q9
k
RECEIPT
DATE 4
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs���
Forms & Footings
�l 9
Underground Ducts
Ducts
Slab Grade
%� 9 g-,44—
Return Air
Steel
Combustion Air
Roof Deckr
Exhaust Fans
O.K. to Wrap
.. <y-Qa I{C
F.A.U.
Framing
t-3-1-00
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
z. —
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
Gas Test
Electric Final
Waste Lines
,�t
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Z7
Pool Cover
Encapsulation
Gas Piping
Gas Test
. Z
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)