0210-072 (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
533670 D hi.c 6,,44W04
Date 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).
( ) '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, 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 STATE FUND Policy -No. 164(462-01
(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 theworkers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: /ia� .�� ,..'PApplicant.�_.'w
Grrr'
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 l 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,;arid hereby authorize representatives of this City to entersupoh
the above-mentioned property for inspection purposes. ' ` `
Signature .(Owner/Agent)• , `�--�'� ! Date f ' "<) .
BUILDING PERMIT PERMIT
DATE VALUATIONLOT TRACT .
26, %
.
301 %.1JOB
ADDRESS 9'('Ja�e45.L`i'1.�i19 AC Rl,
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SW30NATIOMEZ, WC
Sum. DOE C%IAPORA11019
7''7.5fa-4 0C.iWrRY Cr..LU,6DWV`.L?? SUIMV, 137
`7'?m601a.CC7?O1'1RY CUTO1), EW -In -1 1:50
.'PALM DMEWf IZA 92211
PALMA.DES' rr CA. 92260
7 t1 3'?2•' i! 0 nX 113'.1
USE OF PERMIT
SFD - LOT91, PLAN 3 ..PERDAIT DOn NOT 314C`,LUD ; .DOCK
P?'L•.P►W CHECK S IFF, 13119 TO Att•ULTl'P1,9 ISWL1.P.23CE OF S.AJPF,- PL,P, rY TYPE'
CUST014 r=SMUC1TION VQ.00.1517
"
3RCf• IP ATIO 216.00 Sri
GAMMUCARPORT S13.00 SP
14.JV4I 2QtMILD COS"I' Oki' COIdSTRITC`'UDIV
226.54960
F.19RAM FTE S UNMARY
CONS'1;RUC110A FEZ 101.000.4.1,8.,000 31,034.0
PLAN CHECK FF— 101 _000-109-3.18 4219,&
MECRAMCALM 101 -00'J -4t1.000 aia :so
19LEXI' 'i2 CAL -000.420-000 $1X9.80
F'I.I7144MOFEE 101.000-419•000
S TRONO Fi OTICIM FES • .RESIX.2 102 -00-241-000 M65
OkAMNO FEE 101 -(K)0 -4!j3-000 �tS.BG
DEVELOPER AP-4srT FEE
--
ART M MO1~,1C PLACM-1MI1E 270-000-445-000 5607
SUR-°fAL cONWO Rt �xIO A1D PLM,
$4,2Z7,25
Y 2 Ptd' -PA T 0
OOT 17 LUU2
RECEIPT
DATE','�i' ;IMY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms& Footings
Oa
Ducts
Slab Grade
/ — % — t,>_3
Return Air
f
Steel
Combustion Air
Roof Deck
/ -jam
Exhaust Fans
O.K to Wrap
F.A.U.
,
Framing
— /
Compressor
Insulation
z--
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
1
Final
Final —/vr—
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
,. _ %
Heater Final
Water Piping
/
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
Final
Utility Nonce (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)
COMMENTS: