9905-259 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9_(commencing with Section 7000) of Division 3 of the Business and
c4 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
0 LO 613/232rl� LU
Ci�C%:2;1Cr .\►i
r Z r- Date (y (/ I Signature of Contractor ..
O
Z0 0. `` V
J U � OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a
N License Law for the following reason:
Z ( ) 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). ,
C0 () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O
Q WORKER'S COMPENSATION DECLARATION
CL
ICT I hereby affirm under penalty of perjury one of the following. declarations:
:r'< O () I have and will maintain a certificate of consent to self -insure for workers'
X LU L—L compensation, as provided for by Section 3700 'of the Labor Code, for the
0._J Q performance of the work for which this permit is issued.
Q U ( 491 have and will maintain workers' compensation insurance, as required by
Q U. Q Section 3700 of the Labor Code, for the performance of the work for which this
tl rn H permit is issued. My workers' compensation insurance carrier & policy no. are:.
It Z Carrier Policy No.
Cb O ROYAL TNN, CO. 01" s FTC 4.TYir+i'7
g(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions'of Section 3700 of the Labor
3 Code, shalllffo_ ith comply with thoSS fr �vlsl ns.
ate: � Applicant—,$W
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 o Inspection pt rp ses.
1 • iiggnature (Owner/Agent)d` Date 0 � ,
V
PERM
BUILDING PERMIT M -S -2s9 -
tjt,.J
DATC``__ GG 111LUATI0P1 (j�j�°,� ;�gj LOT 1 TRACTJOB
SITE
.ADDRESS 47-8I� �' �Ci� I!, T .'
APN {D3��-�FZ
OWNER
CONTRACTOR / DESIGNER / ENGINEER
!'XVC;T?fIS0F!JJnQ�i'I At C A1,KaRi��t?6�R*Yt/�A1G?
\ a\, +air e L �,R'a.f,� a .,. Sd. V
rt rt`gr:7Y1Yb!\r��t�:Lr'(ik.YG' Y7
,.av A a t:,a,. i.,+, 6 +aas.i l.: i',. c .,. ALJ naJ , a aw
5PA.s'tk I!I,.r1" 8Ufl-P, 400
S ;PAkK 1.5iAZA, SUITE 400
JKVIN,F CA. 926:14
I}LV NE C.A. 92614
i
(949i2_S1-6,100 C:13L.# 5072
USE OF PERMIT
SINGLE FAt`u'41L.1''.I:JWEI:i.LI—NIG.
D-:ViL.AN lke 1A)T 2J 4-AER:MIT WDES NOT INCLUDE BLOCK WALLIS
OR PGROL. k3LM-4 i.tt91ei 1a+:IPORNION OF FIM REDUCED 75%F0R Mi, L'tIPLE .
iSi UANC S Off SANE. PLAN TYPE
TRAIL 1' CONSTRUCTION 1.303.00 'SF
PORCH/PA110 128,00 3F
0A1 NOWC.A&iI'(: RT 4,11,00 SE
CSTIAMUM COST OF CONSTRUCTION
1031,248."
PVIRMT FEW, SUMMARY
CON'MIU(TrIONF'EE 101-000.418-000 $671.04
RL &N C 111t, FRV� )1014)W439-318 $ 40_50
MECk.I&NIC.AL 11`E .101.-000-121-101M 3600
ELFIC'1ATL:AL F M $120.43
Iji,CttVft3lNCi L'� lf)1-i90t1-41,5 —(}� $2426.00
STRONG _ '11OIC FF..E - i7.EQTO 1014100-24114)0
ORA'#J.D.'G FES 101-000-423-M ►.�x►
1NFR A.'w'",f`Rt CRAZE d31~ 2254)00.443-342 $2097,30
01 W-.255-000
ARY IN IYUH IGPLACES - RE,SIr. 7011,'W -255-000-
r.r
t1i PLAN C1 E:
A
$3 589.!7
fAi LEW .i'RErPAIDFE S
1$0.00
�fi�`
9
PERMIT KkS DU>u, Nt?17V
:43,589,17
RECEIPT J
[DAT .
BY l f (
DATE FINALED
INSPECTOR
RKIIt
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
7 -Z-
Return Air
Steel
Combustion Air
Roof Deck
to -77— A ^I
Exhaust Fans
0. K. to Wrap
/- Z -
F.A.U.
Framing
- / -
Compressor
Insulation
_ S'T
Vents
'Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- S -
Drywall - Int. Lath
_rj 7
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
Heater Final
Water Piping
2P I
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
Z _
Appliances
Final
COMMENTS:
Y
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Ma'n Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)