9612-145 (SFD)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of per jur y '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. Dat
- 7 41 88 b
Dat
Signature of Contractor�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury th;�H am exempt from the Contra.ctor's
License Law for the following reason: .0-
1, 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. �044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 704.4, 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. . . .
K) I have and will maintain workers' compensation insurance, as required by
S6ction 3700 of the Labor Code, for the performance of the work.for which this
permit is issued. My workers' compensation insurance carrier & policy no.'a�e:
Carrier Policy No.
(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 .1 should becdme
subject to the worke'rs' compensation provisions . of'gection 3�00-6(rhe Labor,
Gode I all fgrtt��yith comply with those prqvii5�6ns.
Vbatel'_�,, ZKpplicant
Warninil: Failure to secure W&rkers' Compensation coverage is unlawful and
,e��
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,lt
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 informa tion is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizie,rep(�'sentativ.es�6f�t�his City to enter upon
the dbove-mentioned property for inspection purposes. ---
Signature (Owner/Agent)`
DateLM�_;///
PERMIT # CONTROL#
BUILDING PERMIT
9612-145 -
DATE VALUATION TRACT 514 3
LOT
S101.1276110 t9i
JOB SITE
ADDRESS 4.5-041 DUNCArYNAND CGURT
APN
604-2804)39
OWNER
CONTRACTOR DESIGNER ENGINEER
C Et 411 P. Y 0 W C- L L 0") "N I Nil M. r .1-1. C
CENIMIR11" ("'ROWELL CONINPUNMES
.
I i-45 SO. 1D'f sm. u200
RAN 13IMNARDINO t_1A 92408
SM 113FIRNA-k-biwo CA, 924%'
CRJA: 2120
W13NNYUNDIN �ILGIALAR ASKsCIATES
USE OF PERMIT
M,59.PX438X0 AW-_
T(PI !C1, @tA i A QQ fN A. N 0 f 6- r.s
171WIS RE It OF SAUS P
'PLAN CHEXY 11
4,6890"). sill
106,W SF
QY,AKAGftfCARP0.R3' 4 t6,00 �W
F,!;4-1*,6.5t"11'1XD 'Cal T 01r,' CON'STRWIC3,10N.
1011,276.10
'PAMMIT.FIM, SRAI.IWARY
1XI, AN Q4.rX%,.'FWK $2,43.72
(ZO11431'RICHON RT
AIANICAL.FM 110J-000-421-000 $53.50
0.1ic, TRI. R-18 1 1 15�94
PJX_NtEKNORT� 101-009-4194M) $148.00
8! nC - W 1 40 T 10 N FE 8 R FS 11) 101�000,241-�OM
GRAD1,14 G FE110111
'701 X
ART.TN'PUBIA'C PLACMA RF-S1,C A )0'
SAJ'B-TQ_TA1, C0NS-.fRTJCr[QN AND. PLANT CH'F-,CK_
$�_04,78
D" LESS VRF�PAID FEE's
$0.00
TM AJ, PEN IWIT VVICS DUE NONV
$3,504.78.
ri-TV 01F,
[RECEIPT DATE
INSPECTOR
.__[6�TE.FINALED
INSPECTION RECORD
OPERATION
I DATE *
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I / A/
Underground Ducts
Forms & Footings
Ducts
Grade
Return Air
—Slab
Steel
111_711
Combustion Air
Roof Deck
-17
Exhaust Fans
OX to Wrap
,7
F.A.U.
Framing
-7 A
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
POOLS -SPAS
BLOCKWALL
APPROVAO
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
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
5/2/742
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) &/
//'1/ 7
5
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