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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. Datel_�_
01 -5 1 ig 7
o In t ra c t i5�
/ate Signature of C r
rr 7 L,, ---
OWN ER -BU I LDER,DECLARATION
I hereby affirm under penalty of perjurTthat I am exempt from the Contractor's
License Law for the following reason:
( ) 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 excl usively 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 tfie following declarations:.
( ) I have and will maintain a certificate of consent to self -insure for worke rs,
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
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.
76EN11,111f INS,. CC), ZA 201649101
(This section need not be completed if the permit valuation is for $100.00 oe 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 subjdc't' to the
workers' compensation laws of California, and agree that if 1,-sKo-uld become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fortAwith comply with thoselp-rovisigns.14—
V6ate:�7�7. Applicant
Warning: Failure.to secure Workers' Compensation-coverage,is. unlawful and
shall subject an employer to criminal penaltiese�nd civil fines up to $ 1 100,000, in
addition to the cost of compensation, dair5ages as provided for in.Section 3706
of the Labor Code, interest and aftdfn�`ey's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
mh subject to the conditions and restrictions set forth on his
for a per
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, indemnif�.
*& hold harmless the City of -La Quinta, its officers, agents and employee&k i
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 Statella&s' relating to the building
construction, and hereby authoriz4'representatives of this -City to enter upon
the above-mentio�ned propertylor inspddAion_pYurposes7""_
ent Datej7hZ�
Zature (Owner/A'g� �t)"
DATE I
JOB SITE
ADDRESS
OWNER
UILDING PERMIT
VALUATION LOT
4540 DZSCICIF 8NNO
PERMIT# CONTROL#
9612-136 - 4534
- TRACT
APN 1 604,180-049
CONTRACTOR / DESIGNER / ENGINEER
MMAZYCROWELL COMAJINMES CD-11TURY CROWELL COMMUKrIlES
1535 SO. "D" MWl'. STL-. #200 SO, "D- STREUr, S -TE. #200
SAN BERNAK01NO CA 92408 SAN HE'RNAUDINO C -*,A. 92408
CAL11, 2) 20
USE OF PERMIT
NOXIJ7
PLAN 3XV,
AS"'VOCIAIMES
5459 PASSE11tO 01H.
IRACr CON3TRUCTION ; , 1AM1 .40 3F
POR041pi,010 4.06.00 841;
0AItAQEJ4C4�R1�(_1Wf 446m#) SF
MATC.0 CONT OF CDI�NTR V1 CTIoN
10-112"6114 9
PERMIT FEE NUMMARY
PLAN C.34 -t! FLN'
lot -OW -434-318
-000-418400
MEU IMICAL
So 521 50
Ut X!, (11 U C A 1. f t 1,; E
$A 15,%11
PLUMBING V1114
$148,00
3T#'W0 N10140'N V PT, 11,11.4111
3
101-000-14!-
111).J3
RAJ �l N'l
. INFR.ikSTI(vC1-'0Kt-
Al Cl' J 14 PI, I fit, 1 1) 1� &.1T.S - JU:8 11,' 70 1, -0(0 2 55- W)
N. 4
V)AKY�M, C,(.*.)N9fR.1JCfi0N AND PLAN C11E.CK
VD 1. 7S
JAW PRE-PAR)FEE
3 0 1-0-f AL PVRN11T FEEAS OVE NONY
OF LAL
CIT
RECEIPT DATE BYi
DATE FINALED INSPECTOR
$3,802.67
$0.00
S3,802.47
INSPECTION RECORD ..
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
A_;�,,_
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
.4
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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 APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
4/2 �22 7
PoolCove
Sewer Connection
Encapsulation
Gas Piping
Gas Test
5z" -7
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS.
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Extefior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: