0308-238 (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
'7281102 B EIEC
Date ���< `!�.1)?i 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 (Seca 7044, Business & Professionals
Code). '
( ) I am exempt under Section , B&P.C: for this reason
Date r 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.
(1) 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:
CarverOLD REPUDUC R40 Policy No. . PdWC10845400
J (This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the perforniance-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.!
Date: / ; i!". �, Applicant h
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 6f.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.
j M
Signature (Owner/Agent) �� � � Date ,/ '�5 AJ
11 1
BUILDING PERMIT PERMIT# ;
DATE VALUATION LOT �'�'� &I2138 TRACT �~
$1117198,1M Ind 30;s2,�1
JOB SITE.,�v
ADDRESS 44.4 VIA A.9a eOMIM.
APN
OWNER _ _ _ — -
CONTRACTOR / DESIGNER / EN (NEER
UNN,0, .HO S O.1• CAii.T.fr ORNUX
LI'4WAR :G.iOUBS UI? CALTFC1&ii+FIA
78.401 C J'.ITGHWAY I I 1
78.4.01 C MQEIWAY 111
LA QUMA CA 92253
1-6, QT.TiI FrA
CA 92253
(760)777.0131
CM1,4 3434
-
USE OF PERMIT
`a11�'
SSCLO k 1.q, IsI AN �S�P.lr aska IsEit.hrfl I faCifrS AI®T IAf� LUD.E
BLOCK WALLS, P00%:, SP.A, OR DRIVEIATAY APPRO.A.CH
T11ACT (:ONSTRUCTION ,4990.00 3TC
PG' RCWP.ATIO 236.00 V
0ARAOFICARPORT 6311.00 Ma
`
r
EF T'.kM11_D COST OF CON117MU(111TON
CONti4x RIJC'I 1 O FEF 101.000.418.000 $912-1.0
PLAN Ct .W. -.K FEE IU1•tIQ*Jd1,3y-3I€� 5757.fi5
I+lIF IHANICA1, PETS 101-000-421-000 $83.50
ELECTRICAL FEE 101 -WO- 420-000 S 150.739
P1111M BINO FET? 101.000-419.000 UK".
STR.ONO A60TIoN FfuF > pT sm 1101-000-24j-000
tiTi.A.t�IN'C.i`I�F •, 1CSI�UOC)�a23n000 SY:Y,00
d')E1'ELOPFR 9'A,I1=ACT YEE
51113-TO'1'AI. COAIMZ3IMMON• AW) PI—A • CIEMM
s 1,5) 9.'19
dm93 PRE -PALO PT -W
300.00
D a
$4,529,19
,. x PNMT 3. rES ]i;rmm NOW
DSC 151003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FIN E NSP
F
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
Slab Grade
_ _ _
Ducts
Return Air
_
Steel
Roof Deck _
Combustion Air
Exhaust Fansol
F.A.U.
1,
_
_
O.K. to Wrap
Framing
_ _ _ _
`-_
Compressor
Insulation
_
b
Vents
Grills
Fans & Controls
_
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Condensate Lines
/
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/�j _
-5
Final
BLOCKWALL APPROVALS
Final
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 APPE° S
Waste Lines l
Water Piping_
Plumbing Top Out
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral_
_ _
Pool Cover
Sewer Connection
,
Encapsulation
Gas Piping
Gas Test
Appliances
—�
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)