9808-043 (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
'�^nY32�td ,� i 2 3110
Date cilli. Signature of Contractor
a
OWNER -BUILDER DECLARATION r
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
compensatior ,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 ofvperjury 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.
( 0011 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.
STMM FUND 626355-97
(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 provisiops.
'K
d6ate: M ili r' Applicant ca ^,s,,« /r' . .G.n.L �. �''%c✓`
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
'2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for.180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/ �- r F.,/) `x`192'
Signature (Owner/Agent)
BUILDINGPERMIT PERMIT °°"TR°`
DATE���6 V VALUATION M 19.2653 LOT S — TRACT 27f 5
e V
JOB SITE _r
ADDRESS
OWNERjj
CONTRA((C�jTT�OR/ DESIGNER / ENGINEER
[?` (r �j ►/ ( MM[[jj nir//
J:. Ei.C.11AN4@.i.'w •\�ff'•/3� _ - _ —
17,11E
a�V1,.aI:1ti.�Ivil.rl.aJ.'GI,i1:'tt>'1s1. �.\,. ��4.e. "" --
8-613 NtitjLESN DR.
7861 .NAw'LES DRIVE
LA QUIN-t,'A CA 92253
LA (lr ICNI A CA, 92253
USE OF PERMIT
S1Ah: LE ANAL. i)VJ .if✓1Nts
.
Sj+I3, PLAN 3BR, LOT 45 11FAI vi.IT IDEA NO'r i1ti XiDE, BLOC1;. WALL$
Olt P001.. PI,ANI CHEC1+ FFE RIIUC:l ) -79% FOR MULTIPLE I:45UANCY OF
SAWR PLAN TVP1-,. t,
TRACT C014STefiW1:'I(.)114 2;025.()0 SF
S
POACNIP AS 10 S2AU 31
0AcPAC.II/C:.ARPORT 439.00 S1:
Et 87MA 1A.T1' D C;Cb—f OF CrNS7`R:UC1' 0T*%'
119,253.51)
t'.IZ+:i MIT FEF, SM%"RY
C0N'.ST.gkfC r_(O f FEE 101-000-418-000 5709.50
PLAN CHF.rU'`�. FFE 101-0110-439-31$ 5146.98
;iVfF,CHANICAL FIM 10.1-000421-000 $53.50
Fi.rCTRICAL rM :101 -000.47 -0 -WO $128.16
Fi:LfMB1NG ,FEE 101-000-419-•000 $ I40,75
STRONG i'vI0'° ION FEE - RES11~s 101000-241-000 $1 I.9�
OR ADfNG FEE I01-000.42:1-060 V10.00
F, FRAS'.!'KU TUte. FFE 225-000-443-3112 SZ667.64
ART Tki PUBLIC PLACES-1iESTC 701-000-2.55.000 $48.13
SUB-TUTM, CONST'Tt.CJGUON AND 1 [,AN CHECK
LESS PRE -PMD FI3 S
$0.00 -
T4D';EA.:, ff'1:RMIT YCES 1)1:1.Ir,NOW
S%g26.54
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backsz
_��, / •7
Underground Ducts
Forms & Footings
( �J �J
Ducts
Slab Grade
Q—
Return Air
Steel
Combustion Air
Roof Deck
y jd
Exhaust Fans
O.K to Wrap
/2
F.A.U.
Framing
_
Compressor
Insulation
2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROV S
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
Encapsulation
Gas Piping
Gas Test
_
Appliances
Y- —
Final
COMMENTS:
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)