9612-151 (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 7bOO) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. gate-:;;,.
'iti)ixg B I-,- :::;>G-_1 I i97
L
4nature of Con'
VDa-te 7, tractor,"
OWNER -BUILDER DECE`A�RATION
I hereby affirm under penalty of perjuy
,,,trat I am exempt from the Contractor's
License Law for the following reason:4
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. 7044, Business & Professionals Code).
( ) -1, 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 Ow . rier
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following cleclarations:
I have and will rnaintain 6 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
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 Policy No.
ZVNITH MS. (1:0.
(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 perml issued,
I shall not employ any person in any manner so is to become-s--u'bject to the
workers' compensation laws of Califorl and agree-thatl I. should become
subject to the workers' compensation provisions of -Section 3700 of the Labor
de, I shall forth ith,Comply,,hith.thospprovigionsI
Date: pli
Warnil Failure to secure Work6l Compensation coverage is Unlawful and
shall subject an emplo�er to..c , il penalties and civil fines up to $100,000, in
'w'�
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 here ' by 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 a
0,
whose request and for whose benefit work is performed under or. pursudnt 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 cancel lation.
I certify that I have read this application and state that the above informatibh is
correct. I agree to comply with all City, and State laws relating to the build - ing
construction, and hereby authorize 'representatives_of-thls City to enter upon
the above-mentioned property f6� inspectionvu-MPO'ses.
/Signature (Owner/Age—ni) Date -
PERMIT# CONTROL#
BUILDING PERMIT
9612-151
4549
DATE VALUATION LOT TRACT
110
A�
JOB SITE ';
ADDRESS 4L -1,10 D&S ASAND COUR117
APN'
OWNER
CONTRACTOR DESIGNER ENGINEER
C11"HT011Y 11 M01WE111
C WITM ft Y ICRONVEI, L' MAIN'. I IN III E S
15.15.S0. " W ST -K E U. - SIT-. W-200 -
90. ftQ'STREk3*,S1T_ #200
SA -N 13911NARMN0 CA 92408
SA.N IIERMARLANO CA 92408
cat.# 2170
130-4.11 AMN
USE OF PERMIT
S459 PASSER() AN111-L
TOPAZ (tt� Qt4NTAN0k;fi3
Cll F116r, RFL)MR) FOk MV01PLE ISSfift 0.1, SAMEPLA'"
TRACI* CONSIRLICTION '"'1073M SF
SF
5
GAP.AG'WCARK*-',T 576.00 SF
'IN
cSTr%1,kTLT1) CoST OF CONISTRUL 110
124,69114 .441
PFRAUT FERK:SOMIMARY
PLAK Cf1FR,X', FhM 101-000-439-318
C'0P4,v;I'RJJCT1(YN FRE 101-04-418-M $727.00
MECHANICAL rEES Wl -000-421 -000 $79.00
.101-M-419-000 $167.21
101i -000-_1414M
101-000-423-000
INI-RASTUCTURLE 22_5�"-"3-3C1 S Z 7 %K? 0
ART Yq PfJtAL1CPLACt8 (IMS) 70 1'_000-255-Mlt $61.73
$4,263.15
LESS �.TAJWEES
PRE
$0.00
TOTA14 PFUMITFFMI� DITNOW
$4,263.26
DEC 16
L AOLJINTA� i
uTY bF
RECEIPT
DATE
BY
ED
INSPECTOR
INSPECTION RECORD,
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Footings
Underground Ducts
Forms & Footings
Approval to Cover
Ducts
Slab Grade
Return Air
Steel
/67/ ;r
Combustion Air
Roof Deck .
4Y
&
ExhaustFans
O.K to Wrap
Electric Final
F.A.U.
Framing MIW�Wz_
Water Piping
Compressor
Insulation
JV/ //7/
Vents
Fireplace P.L.
Sewer Lateral
Grills
Fireplace T.O.
Encapsulation
Fans & Controls
Party Wall Insulation
Gas Test sl'xl� "'a -7
Condensate Lines
Party Wall Firewall
Exterior Lath
COMMENTS:'
Drywall - Int. Lath.
Utility Notice (Gas)
44a/,�h I ,
Final I I
Final je�jj 7/
POOLS -SPAS
BLOCKWALL APPROV�(Ls
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
I /
Electric Final
Waste Lines j
Heater Final
Water Piping
Plumbing Final
Plumbing T6p Out
Equipment Enclosure
Shower Pans J
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test sl'xl� "'a -7
Appliances
Final
COMMENTS:'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)