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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
640934 Fj 0 1*31,1x(
Date Signature Signature of Contracto(�
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 workl 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 • /
( ) I am exempt under Section , B&P.C. for this reason
Date rSignature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaliy' 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
Seotion 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 NATIONAL 'UNION F Policy No. 70833,09
(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 provisions..
t
,Da`te: iti._�1 l x`'° Applicant �'wy-* f`:,.
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, indemnity
& 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 hof this City to enter upon
the above-mentioned property, for inspection purposes./ j {�
signature (Owner/Ag4nt) -� 1 + X, Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 03T.t-078 TRACT
14 / . ; , $x ,677.40 40 300x3
JOB SITE r '
ADDRESS 81^9DA M DIUVE
APN
716-4-270-018
OWNER
CONTRACTOR / DESIGNER / ENGINEER
8WEA,,1~zt7MES
DHEA, HOAi.&S
81-260 A' TN'► E 62
81=260 A:4TNr3E 62
LA Q=A O.A 92883
d.wA c"i.1TNTA CiA, 92883
(90.9)83;-8996 MU 68'76
USE OF PERMIT
MWILEFAM1?','ff.'DWKJ la G,
SP..0 - LOT 40; .PLAN 45100. PF32.1V IT DOES 140T INCdL.U09 11L OCK
WALIAO, P0014 SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRU'c Tiow 1,7".00 9P
P031CHIPATIO 45700 S3?
(kU.i WCARE'ORT $62,00 SF
XSM MCAT= COS,"r OF CONS'MU'Oi10K
155,677AO
PERMTF=1161M 1 lf(A1�V
CONSTRUCT ION 'M 101-000-18.000 $83150
PLAN CHECK IEE 101-000-439-318 $692.89
MECHANICAL FEL 101 -000 -421 -WO $93.00
1&=TRICAL,FRY, 101-000.420-000 $107.01 ;
PLUMBING F'EE' 101 -OW -419-000 $147:03
3 T RONO MOTION FIZZ • RBSID 11,01 -000441 -000 533.5'
ORADINQ FEE 101.000.423-000
Dt-VELOPFR IMPACT FrEE$�0�4�•00 .
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RECEIPT
DATE
BY'
DA(FIIIID 7� `
INSPECTOR
U
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
A
Combustion Air
Roof Deck
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
BLOCKWALL APPRO _S
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 APPROVALS
Gas Test
Electric Final
Waste Lines
p -L5_,0.3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
d—[ O 3Sr
Encapsulation
Gas Piping
Gas Test
Appliances
Final
-
Final
Utility Notice (Gas)
ELECTRICAL APPR VAf S
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: