9905-251 (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 # Lic. Class Exp. Date
63 2. 't a 021291204
Date � td " Signature of Contractor lrlloL "5 w
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).
() 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 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.
',(4)3 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:
Carver Policy No.
i:01'AL INS, Co. OF -i VrC 45. ,
(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 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 700 of the Labor
Code, I sh fo hwith comply with th
�Applicant-
"Warning:
ouisio s.
Date: ' �'� Applicant
"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 pursuant5t0
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 f r'nspection urpos S.
/Signature (Owner/Agent) -Date 44
BUILDING PERMIT PERMIT#"0.-1
DATE
' /' VALUATION .Sn4.3.30 LOT xR = _ - TRACTJOB
SITE
ADDRESS 47-815 SI,TMWA * ST If��..g
APN
OWNER
DEPSIIGNER ENGINEER
y� tit t
�y�1k,
pp YY C��Sy �� �yq TLA
Ctl .Ia�+..1,�1..1,S R.. a) S.IJ.I;.N i+.LA11., C0 N1 k, kb)l.V71 1„i+�.IN
tC7�ONTRRtA�CT�OgR7/
a A `+�+� 7
�.�Ki T. 1..LUS i:�la DE i�IftAL Ci7i�ot,7 a.YwY.,crT.IS.0.iti
5 Plvui fi L".,A, SUME A 1 400
3 PARK PLAZA, SUITE 400
IRVINE CA 92614
R:VINE CA 92614
(9.49)251 .61 00 5072
USE OF PERMIT
AF -D - PLAIN :3AR LO d 38 - 13LC Millf DOES fdp'.t'' IWOLi,IDE 13LOCK WAF iia
tXt POOL. PLNN C1•fC:1: P01d:i' ON• 0 rW-. Ki:DU( 7S`/b FOR MU1.11 >ix
ISSUANCE OF SAMB PLAN TYPE
T R d= CCAi ISTIR13L"'I,T0NI 4>i97.4t3 S
POW W?ATIO 124.008F
GARAJ3FJC1UW()X1' 430.W Sr
ESTMIATED COST OF WN43T.-1;',UCf [ON
1,24,336.30
PItM13T IVES SUMMARY
CONSTkt1C`T:1CaN HEE 1t71-000.418-000 $727.00
PLAN C1 -M CIS. FEE 29
NIEMI `MCAT V M 101 -CM -421-000
Jk_LJTC"AMCAL ;FE8 I U,14*042n-000
PLUMBiNOfl ' 101 tH0-419-000 "Sitit).ika
�M.O NO M-URON FF37 - RESID t 0-1-W_ -24'1:-131147 312.43
-ORADINCY FE.l 101.000-X42.3.000 =0.00
[ikMAS`F'ii':C1c,'.'1UREFF% 225-000-44-1-342 52,760.46
.Al r .[N PUBIAC .N1 AGES - Vit[ SID 701 -000 -254 -ow $60.84
x.
4.
e' `p
-.TM,A:!, t;°01,VF P 1R1afCJ 11QN AND PLAN CHECK
S44,i410 d?
h 99 U.SS PP.,RF4)A1D F.CES
TOTAL L PKRMff FFE'S I31,TC NOW
fl
S4,00.42
4�
RECEIPT
DATE
tbY /j (
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
s
Exhaust Fans
O.K. to Wrap
• -[ Z - S
F.A.U.
Framing
to -zo _
Compressor
Insulation
V-* S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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 LinesHeater
41
Final
Water Piping
W16 L rT
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
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 -Z '
Utility Notice (Perm) Z - 7,