0007-125 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm uhder.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
•Date.Signature of Contractorr
OWNER -BUILDER DECLARATION
I hereby affirm, under penalty of perjury that I am exempt from the Contractor's
License Law f6r the following reason: . . t
( ) 1, 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. 704 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 Se&ion B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm un . der penalty of perjury,one.of the following declarations:
I havE�ancl will maintaina certificate of consent 16 self -insure for workers'
compensation, as provided for by Section 3700 ofithe 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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
pubject to the workers' compensation provisions of Section 3700 of the Labor
'Code, I shall forthwith comply with those.6,fbvis ions.
ry Date. 7 Q 2 Applicant ZZZI
-
Warning. Failure to secure Workers',Compensation coverage is,unlawful and
shall subject an employer to criminal 06'nalties 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.
1.1 Each person upon . whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant,tot
,,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 pUrposes.
I/ > Date
�//
-r
§.;ignature (Owner/AgBnt) I
—
-BUILDING PERMIT PERMIT#
DATE VALUATION 1.. LOT TRACT
=54U5
JOB SITE
ADDRESS
�M,A VAf,I TO
APN
4- -02
77.141. �0
OWNER
CONTRACTOR/ DESIGNER/ EN61NEER
Rf M-4RD 0. CROCZWr
OWNER/J31011MER
PO BOX 604
LA QTYMI!A CAk 92253
C11-10
USE OF PERMIT
MG.0 FANflLY DWEII-W(I
SFD - PEkAdIT DOES NOT INCLUDE BLOCK WALL OR P004
TRACT CONSTRUCTIaN 1,326,00 OF
PORCHIPATTO 459.00 sy
GARAOFYCARPORT $46,00 8F
5 FT. WOOD PENCE 200.00 LF,
EgrMATED COST Olt CON9MUCWON
1w,M.10
PERMITMSUMMRY
CONSTRUCTION FEF 101-000-418-000 $646.10
PLAN CRECK FEE 101-000-439-318 $53919
MECHMICAL FEE 101-000.421-000 $60.00
FZWTRICAL FRE 101-000420-000 $133.83
PLUMB1100 V.99 101.000-419-000
STRONG MOTION ME - RESID 101-000-241-000 $10. i4
GRADINO FEE 101-000-423-000 $20.00
DEVFJA)PL*R IMPACT FFX
PRW1OX 1) LAW 101-000-441.345 st00.00
ART IN PUBLIC PLACES, USir- 701-000.255-000 $3.42
FEE DEPOSIT 101-000-439-318 f -8230.00
;AWDOTAL db,1�kRUZT109 A14D PLAN 121-MCY,
$3,53 7.33
JMB PRE -PAM r -MS
-$250100
T01AL PMMr IMS DUL NOW
PID
A
JUL 2 1,2000
.01 VI OF LA,QV '2
RECEIPT
DATEB
DAT
INSPECTOR
t2 J/1 L
V
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
/ 5
Exhaust Fans
O.K. to Wrap'rjT
F.A.U.
Framing
ST"
Compressor g
Insulation
b S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
01 67—
%Drywall
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
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
NAM �j
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Utility Notice (Perm) 1491 V/
COMMENTS:
),�s-�1 /
CITY OF LA QUINTA
FM OFr�6 BUILDING & SAFETY DEPARTMENT
777-7012
INSPECTION REQUEST LINE
777-7153
Owner
Contractor
Permit Number
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 11-6 TS7 Mle.So7S
TYPE OF INSPECTION
DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL '
MAIN GROUND SYSTEM
GROUND PLUMBING
g O
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT - A/C
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP
GROUT ❑ 4' ❑ 8'
FRAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR z - L_ g /
EXTERIOR LATH _ L _v
POOL PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK
FINALS
F'LU M BI Nei
FINAL GAS TFST
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN 0 l TILITIES OR OCCUPY BUILDING