9606-068 (SFD)U)
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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
:� idlSis H % (►ii��7
Date�jSignature of Contrac
OWNER -BUILDER DECLARATII NN " .
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).
O 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 Or.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 '-f dl 1'11.it�1u. CO• Policy No. 2442fN'it�i961
(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 Calif ornia„and'agree.that if I should become
subject to th°.workers' compensation,provisions of,Section 3700, -Of the Labor
Code, I shal fo hwith comply with those p'rovision's.. • -”'
Date:Applicant
Warnin : Failure to secure Wog ers Compensation coverage is unlawful and
shall subject an employer'to criminal penaltiesand c�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) " Dated �`✓ l
# °°NTR°`#
PERMIT9606-068
BUILDING 06
n� sPERMIT
DATE VALUATION . $+1(%2+".3.0 LOT 2a)
+
1 - (42
JOB SITE70-3.25 imsi.+"W ckai�9 . oww- -
ADDRESS
APN 604_33�i 020
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CE CROWELL CONROU'NITIE;
CEl<!':"U1t`'' CF:Q�'Jl:�,i. CO1111�ItINf1'i1��S
1555 SO. " 13" S #t ET, STT. 4200
1535 SO. "D" �',"1'REWT, �"i�'. r.':2.(1t)
SAt1f B'ERNAl DW, CA. 9240K
SAN SERNA:I DING C.A. 9.2409
(5�£)�ln�R1. Qt17
01381-1007 f.;U H 2120
I9.C141A1VIA4Y Av1+.11 tits ASSOC. IN -C,
USE OF PERMIT
SINOL8 rAA4.11 Y DWELLING
5459 1'AsSHRf} AAVi.
. i r.a-l..li- it CA ysti 5
TC-PAZ.Kr, LA (X r`I *A NOR:.rE
1,689.00 SRF
'CtR+ Fit1�A°l'(t� 106.06 Sr
GARAO]Dt.1 ZPORT 416.00 Sr
$STFAiATED'.Yf Op CON.S RUCnON
10J,276.10
PERINIff PRE SUM -MARY
PLAN Ct31ECK I.1 .. ia-IMt►--1����€S �i�1.PI
u WSTRUC�'lt'0�4 £ 1SE lu4=OvG41°-�,' $6546.50
Diffi(``i:TANICAL F" • 14.i <i3€JU-X21- i1� ' &SKS6
v'
f±falaf.,E`111.GA1..4 :E. 101-000-.420-000 SIJSf 94
rn ,
S`,'(:aNG MOTION KS - RRS1D i0i-000.24.1"000 516.1:3
r -t
GfZ60UlN11 .101-000-423404 52t).ilq
1NFAA3'tRLTCt TRE- r"FIT 225-000-44.1-342
A€S t IN PL63LlC, KA..033 - lifs ,l1: 701 Ot?0-'y5S-C?tJ(� � . � � � 524..01!
SUB1WAL WNg c UC 310N AND PLAN CHECK
�3,St12.67
LESS PRE-1,`A[D FEES
moo
TOTAL PERE :iT FEE$ DUrt.NONY
53,13Q2.��
RECEIPT
DATE
BY
DATE EINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts -
Forms & Footings
Ducts
Slab Grade ro
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 44
POOLS - SPAS
BLOCKWALL A P OVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 ladPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final -
COMMENTS:
Final
gz:44Z
Utility Notice (Gas) 26M K:v
ELECTRICAL XPROVALS
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)