0209-086 (SFD)- r ' LICENSED'CONTRACTOR DECLARATION'
I hereby affirm under penalty of perjury that l am licensed under provisions of
Chapter 9 (commencing with Section 7000)p6f Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date,
Qatef? ti _" Signature_ of Contractorf _ '" f° ,°`'� +'^•` °'`�`5
T77-7=7
OWNER-BUILDER DECLARATION 1
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). c
() 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 l 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. -
S�( ) I have and will maintain workers' compensation insurance, as required by
tion 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 STATL,FUND Policy No. 07152
J (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
Code I shall forthwith comply with those provisions. °
Applicant
Warning: Failure to secure WorkersCompensation 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 af?
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
!o & hold harmless the City of La Quinta, its officers, .agents and employe
�y 2. Any permit issued as a result of this application becomes null and voi &j�
work is not commenced within 180 days from date of issuance .of SLY
permit, or cessation of work for 180 days will subject permit to cancellati
I certify that I have read -this application and state that the above'informatio
correct. I agree to comply with: all City, and State laws relating to the build g,
1 construction, and hereby authorize representatives of this City: to enter uon,., .
/ the above-mentioned property forinspection purposes.
✓, Signature (OwnerdAgent) + ~ r � °� _Date f 14 •'W
BUILDING PERMIT PERM& _ -
+
VALUATION�vvpp��ry �l L �ypy LOT TRACT ryF�r 9e eft'
DATE VALUATION =742100
-
= 7,1' 21 0
301 A5-2,JOB
_
iY
SITE
ADDRESS •�< .�t .7�7 e .'COi1 Z�6
APN 773-M021
OWNER
CONTRACTOR I DESIGNER / EN &NEER
MI)ONA H01 W.,WC r
sumosl compo12A. TON
'77 -564 C•°C►M":I Y PC: B DrtRfle tU]i'I,' 137
77-645A C''0(JXTPY C'.'i.UB,:t RI V1I SWIM 150
PALM DESERT CA !V2211
Pyry.�Y/..yAAy.1q"sry rr�i,�tp£ CA a2260y
(760)172"'224 CIDLh^ 1
USE OF PERMIT
SFD - I.V& 3, Pl-AW 1. PERMIT .9093 NOT 1h1rLUr1K BU_tt K °W -&IX% '
000L,91% DRWZM�V APPROACH
Cti'nom CONSTRUCTION 2480.00 3F
�OPaCk'tiPA I'IO 12 4.0 sF
MWATM COST' OF ('fir` EMMMON
207Al2.211
C01QtAUCT1a.H FLM '101-000-41R,000 11;017'so
ELAN CHOCK FEZ 101 -WO -4.39-316 W9.4(1
1IMC1` "ICAL FEE 10'1 �0il i- 4211 DO 1 $109,00
E1C7°RICAL TTE 101-000-4:2.0-000 $:1:43.56
PLU ,4BING FEE 101-000439-000
ST$%JY0 MOTION PER < W -11D 1 CY 1-000-241-006 $20.-A
t;flz'AT1Il O FEE 101 -Wt -423-000 S 15100'
D—WEL.OPER IMPAX"1' FEE $2,403.0.0'
.ART IN PUBLIC PLACM - .RUM'x'70.000.445-WO
-°f0'1A-,CCWft:EiLtC'r109 AWD PILAW 03K
I.JESS PREPAMFXEZI
TO -a r�f%m.'rus. m ,1` now
U-11
T44714,60
SEP 2 luU2
CITY OF LA QUINTA
D
BY $
DATE FINALED
III,SPECT
s J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
J-7-
Underground Ducts
Forms & Footings
Ducts _
Slab Grade
-- - L >
Return Air
Steel
Combustion Air
Roof Deck
— /y — Z
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
/--2�-<
Plumbing Final
Plumbing Top Out
j(
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
= _
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring — 2-2
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) —/ —
COMMENTS: