9808-047 (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
ate /l t�' � Signature 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 Policy No. -
STATE 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
ode, I shall forthwith comply with those provisions:
ate:,/l�/1t/ Applicant 'ley'�.nJ ./`J.
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.
Signature (Owner/Agent)//�'%jl,% drJ Date ?" t�/a
' '`BUILDING PERMIT PERMI a" °°NTR°`"
DATE [/ VALUATION LOT -' TRACT n
;:419
4 F7JOB
SITE
ADDRESS r -` 9 d� 1�C:1�. I)RIV ,
APN 6091 080.013
'OWNER
CONTRACTOR / DESIGNER / ENGINEER
`! 117 `F!XCHAK101E i, 80101 y
79.6 NAFL2S DA
.OR -WE
L.A. Q1UINT.A CA 92.253
LA. UINTA C.A. 92253
C769)772-0222 CBM 1.M
USE OF PERMIT
S11NOLE FAMILY WELLING
�
SFL', PLAN St31Z. LM #1. PERA t 1' E?t`31 NOT 1N(MLADR ELOCK Vy'tiUS �
OR POOL PLAN Cf` UCK. �E. icHi�i1C Er) 75°foFOR N LTI113LE ISSUANCL Ol
SAMT PLAN 7'i PS,
l
�
\t1A
TIL,, :r CO3,114aTRUCTiON S
F'ORCH/PiV 1710 160.00 .SC`
6ARAc1MAruOWr 44.9.00 SF
',E,�t"�.'IMAT ED COST OF C:IONIS'1rRUC"110N
14.1,x=13.40
PERAW FEE SUMMARY
6 Ns-rRUUric)s rm 101-m-41.8-000 S736.550
PI..,AN L`T11rM FET. 1.01 Aw. -Q3111 -1 18 $161,98
ANJEC_IRAXICAL FEE 101-000-421-000 160,00
RLEC'MCAL. FF9 .101-000420-000 $141.4$
1:it.0Mk1114G FEE 101-000-41.9-000 $140.75
uTi MNG, MOTION FRE - :R 69f 1) 10 -W-241-0015 14.12
GRA13t'NG FFF 10:1-000.423-000 X7,.0100
WRASYRUC't'CJMi FES 225-000-443-34'a• $1,10.21
ART TN PUBLIC PLACES - iLi51133'701•-000.255-000
SL BB -7 A -L (.,'ON tUC,''I`fON :A.N!� Pi,A]� r CHECK
$4,559. 1 t
'LESS PRE -PAM FEES
$0.00
'.LkMDT FE CS OUCNOW
$4--5588.16
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs��
Underground Ducts
Forms & Footings
( l
Ducts
Slab Grade�G
li
Return Air
Steel
Combustion Air
Roof Deck
e'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
-,
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
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
Gas Piping
Gas Test
_
lc`�—�1
Encapsulation
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
C
Final
Uglily Notice (Perm)
COMMENTS: