9905-035 (SFD)LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that l 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' ,' 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.
Q- 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 carver & policy no. are:
Carrier Policy No.
GOLDEN I-3,4LOLF TNS.
(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
sub11'ect to the workers' compensation provisions of Section 3700 of the Labor
Cyy2,1 shall forthwith comply with those provisions.
Xate: Applicant
Warning: Failufe to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost -of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to,
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the. City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
-permit, or cessation of work for 180 days will subject permit to cancellation.
certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
,.Signature (Owner/Agent) f..�� % Date/y
PERMIT #
BUILDING PERMIT
9",
DATE VALUATION S1116,968.20 2390-4i ,'_' TRACT i 1��y5 f)
!'. :"
JOB SfT ' /
APN
ADDRESS 4i-425 D1LERS$Wt; K tC'QAdCLCu+
6"040-016
OWNER
CONTRACTOR / DESIGNER IENGINEER
0E. RJV,`1.` tiOWTLLt:/6dUINIM(S
"%NTUiYvi\,MR-.i.
V: 35 so. "I:.)" ST'I:.Eiif, ;"11-1. 111.00
1535 SO. -D" ; kEF,, 1, SIT. #2200
SAN BEWNARIMO CA 92408
SAN 13E'R'NtRDINO CA. 911171.8
)391 _6007 C'af,ff 7.121}
USE OF PERMIT
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SrI + -1.i1l ? f'Gra1v Sfi -1°.t• 1lT' i1Cilsti N()"1' 1M(:Li�f]ii 137.i�-:f;. WALL OEC
Fr001.. ''75°ro PLAN C:118C C FIX Rkli lUi"!`ION VOR NIULT'IPIX 1S31JANCE
SAME 111, AN '1" YPI,
'rRA.0 T CONSTRUCTION. 1.''.16.00 SF
0AWVGtVCJkRP0RT 69880 ;YF'
ESTIMATED CMYOF CQNSTRUX710N,
106.963101
1'>ifi;idA'iTI T FEE S11NM.ARV
CONSTRU(7VIr:>N F"M 101-000-418.000 %664.0
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t'LLINIJ 11.10 F'FLE 101-OW4194JI00
STIi;(?NO M(l'1'10.0 FFF - R17810 1(11 _(}01}.7,11.(1011 $111 70
Q �lZ Al11'!Jt 1 l !:L 101 1)W- 4213.000 $113.40
6 RAS 1'Rii+~,`I'URP FEE, 2254)3441 -342
ART I .1N.BLIC PJ,ikC F3 - RES.U.'. 701-000-21.554)01? 517.42
8-t ("t')NS1Ttl, 7110N AND PLAN f':!'1.F(-.'!c
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LESS I'j.:P41, ID rTES
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' 01*A1., PD+�RMID7T it EEN .DUE NOW
S3.560.95
RE T_
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWL®ING
.APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
7
Combustion Air
Roof Deck
.- 3.- 6
Exhaust Fans
0. K. to Wrap
�� —$ . 'C
F.A.U.
Framing
91 49 Av"
Compressor
Insulation
/O—%Z=
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
v —
Drywall - Int. Lath
A5 B
Final
Final
Z--! —
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval. to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMffING APPR VALS
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
— 2
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)