9905-253 (SFD)LICENSED' CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
-_Chapter9 (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
63722, 8 01.'29i21h
Pat, tri 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 at 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, fdr 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 Policy No.
IROYA1. INSLIW. OF e PJV 41 92287
(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 sous 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
Code, I shall forthwith comply with •those • j�v Sion
"�' 10 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 j�,;
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 urposes.
Signature (Owner/Agent) Date-- t� _
t BUILDINGPERMITPERMIT PERMIT#��2�
DATE ea T _VALUATIONLOT -,T _�__= TRACT
ADDRESS 47.975 -SUMAC n41.�.i4i' r;
APN 49-030-020
OWNER
CONTRACTOR/DESIGNER/ENGINEER
/ry�1 'i [ '((Y ! IC !:e' Fi�17r.Pj !'
\.t'1.111EY.q h+Wtii .RUf TnioA,A! ai3:A.L1'`...Vdl'.4:Li.4t,J.i:0 { .U1ly
f !r (Y A ry !,•! 1 '! iG° j] y cy:ti�AY'q A' ti tK'YW") i{Y['!r1 1
6lYL t.✓.4'1.{Ai{.:f 1,a11:JA lr Al}0.Jfit V.i .{.!' .+ �✓.}tifJA 0.�.�\s (..L4/jL
r� R f €1.Erl. t, &1 i T E1t}ti
a :1)�t,:f�K PLAZA, SUITE X100
IRVINE 77A 92614
MINE CA 92614
(949 251-65100 0131,, 50,712
{ _
USE OF PERMIT
_
SINGLE VM—I:ILY 1��d.1�.LLINii
iN °I.ITGr; AtOC;K ids LIS
Oft,1',i'' O.L. PLAN CHECK POR°1 U N OF'F•g RRINC ED5.o F(_ -),R- t14L9.'1'i1 L E:
is fdtNt. c� � PLXN'r TIE
TIZA%T i NS'['.12:t:1t"i;if fit 1,914,00 51
Pf,: RCHAIA1"IG I:'l.}.00 `s%
0ARA(3O'Ci 1tl 6RT 483.00 SF
LMMATFED CM. T OF CYJN.S'f RUCTION'
114,W31.00
PV4, Y.MfT1 E SUMI1*'i(kiR
CO!V 'CttZ7 'TION I 1 101:-0110418-000 S692.00
1">,AN C'RECK FE Kl -I.s-43g.3138
f C(4:}1tOCAi M� 1 101-0001-421-000 UG.QC
1- EA-. Ri IC A L F EE 101 -ON -420-000
PLUMBING I<1713 101-000419-000 $154.00
STRONG Mi;)'.1"ON'FIE.V,-R-ES.lV 10.1-000-241-00e S11,50
S:C0.00
-000-423-0}00
-
yGRADfi(�.1ata�{:1REh P�tf 77 T+ �•.-1y�0y1
p
NFR UC to
ART 1WOUBLI'C'F1 ACHS-12IM0.1,�000-255-000 X2,4
a
Rt71i-?K r4%L CONS U.CD`ON �i.tND PLAN c''1=4ECK.
13,W3.36
LESS PRE -PAID FEES
$O=
SUN 1999 Tc TAL VERINItT MCI UENOW
$3,1%3.36
LA �ai
[I
RECEIPT
DATE
BY 4 1
DATE FINALED
INSPECTOR
T ,
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
Exhaust Fans
O.K. to Wrap
_,o - EF _S71
F.A.U.
Framing
c . —
Compressor
Insulation
— Z — g
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
L,S =ie47 57
Drywall - Int. Lath
—
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backszx
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
Heater Final
Water Piping
Wt
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
1A— — Q.
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit '
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 2-7-0