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LICENSED CONTRACTOR DECLARATION z ._
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 Ezp Date
7' 1 t#1�
Date / Signature of Contraco.�-
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 tf e -project (Sec. 7044, Business & Professionals
Code). rte.
() 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. l
( ) 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 ' 71,M11i INS. CO, Policy No. 204206 6,401
(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 rprovisions of Section-'3700.ofthe'Labor
Code I shI f `rhwith comply wi h•those•proyisl
Date: _� a ..Applicant'
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
Signature (Owner/Agent)�� Date /
BUILDINGPERMIT PERMIT# i CONTROL#
►6.067 3 513
DATE — VA 11ATION LOTTRACT
'587;174.40 24
JOB SITE
APN
ADDRESS 79-315 DESERT CIMST DK E.
6"332-019
OWNER
CONTRACTOR ! DESIGNER ! ENGINEER
CENILT1;.Y 0,1101tirFLL COMMUNI[T1E..
CER1'C{. RY CROT4'E'L:L Ct?MMUNIMI'S
1335 SO.O” S1`R•Err"S"rL:. kno
1535 SO. "O" STRU r, SIR #200
SANT 13HRNARC).UNT, C.A. 9,2,408
SAN BERNAktt INO CA 92408
(904)381-6007
(909):381«6007 CML.4 2120
ArNJrMIN AGILM ASSOC. INC.
USE OF PERMIT
82 (AA4,FAMILY 1AVs1LNG
5459ASSW> fiAVE
IsME25iID , CA 5210.
TOPAZ. A7' 1,A QUINT.A N0XfR
PLAN 2Mj. A
T 2JIVI'1' C(:}'t 111 RUC710N 1,433 00 SE
PORCH,lMA.TI.O 85.00 Sr
GARAC UCARPORT 420.00 SF
F..STiA1ATED C%J,ST OF CONSTRUCTION N
87,174.41)
Pi:;A'K CHEC,'1� FOR 104-000-439--31.8 S495.77
-
CONdSTWC:'13024 FIX. 10k000-418-000 x()00.4113-000 $5135.50
1M ECIIANICA1..0XI. 101-000-42.J V0
.
1r1.f3=tilt=N..V1:li ' -101.mo,-420-000 $1.0"
X t?t
17-1
`
f-'{ttfNffgNtN 1<TF1 01 ! 1 J 9-000 $148.00
SIOi+fr: NIQ'; IONPM-1� SO) 101-000-2c41-400 $18,72
aitAt:fNofFIM 101-000-423-000 1.20.003
Q _I
#'N RAS 1'ItUC*11JM FTFR 225.000.443-347 $.1.935.99
�
SUB -TOTAL t✓OM.�'I.RLlMION AND PLAN QUECK
$3,354-54
LESS PRE -PAA FFES
$0,00
. . .L.OTAIJ AIER.M..r t.L'.1N DI A'. N4JW
$3,354-54
RECEIPT .
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
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
Final'
BLOCKWALL APPkOVALS
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 APPRO ALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
fEquipment
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
ell
Pool Cover
Sewer Connection
d7l I UEncapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL
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)
APPROVALS
!
COMMENTS: