0305-241 (SFD)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.Zate
640,434 I3 ;a / fj5i,' ow
•Signature of Contracto,/�l
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 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 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.
( ) I have and will maintain workers' compensation insurance, as required by
Se bion 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 N A.TIONJU, U14ION Y Policy No. 530
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any mariner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Sectiom3700 of the Labor
Code,$ I shall forthwith comply with those' provisions.
Date-( / �) 4> Applicant_a
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
additiori 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 tol I
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. UUU
I certify that, I have read this application and state that the above informationis ('
• 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-
{mentiiohed property for Insppection purposes.44
( 1
Signature'�(Owner/Ageni) t' tYDate S 01
r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT •-• .TRACT
30013 .
JOB SITE
ADDRESS Y� QTS ICD mayuRr
APN
ITC4--2 70-017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Xf AHOMFA FOR AC`iTO, ADT37 '13
1kiF-4 HOWLS
.60-311 I.XWOY FARKW1. Y .
81.260 L•IW1Ti E- 62
Lt, Qm wiT A CA 62233
:1'111sLRM.AL CA 92883
(909)833-11996 OBIA 6376
USE OF PERMIT
SWOU
SFO < LOT ISO. PLAN 3311513. PER.MI I)ON i4 Of IXCL U1JE S3L0 i.
WAEA POOL, SPA OR DRIVEWAY APPROACH. 75% R1;'IL7Edf"TION'PO'F.LA:N
CHECK FEE DUZ T O MULTIPLZ 1'SSiI,F' 14CZOF SA&SE PLAN TYPE,
CUSTOM C'•ONSTRUCT1014 1,1121,00 SF
0Akt.s0F1CARP01I'i' 45b.ft0 F
x vrn4ATED cosi C)1~ ®mYT ®
1-'3,"J3a2X0 .
CONSTRUCTION FEE 101-000-41"00
PLAN CHECK FEE '101-'000-4'39•-31:3 3.166.'x7
MECHANICALFEE 101-000421-000 %ftso .
.
R1:.ECTRit°A1 Fft 101-000-420-000 $108.36
PLUMBING Fid .x 101 06�=419.000 $124,00
mom 1t6G4vow net,, vztsm 1 Q i -o 0=24 i ••000
,
ORADING 'r"r,� f .101-'90tdwi?:?-flili3 $ s.013
1EV1,AR',1hQPAC7" 79F
' 8V_B_T4YrA:.I LiON37. L4L%{.I.l101f Akm MY"1I.?! CIMCK
rt"729..50. .
7"CaT,l�1 1" . CiV1t ' iP" ,1 5 ; 8'4 NOW
2.729.50
RECEIPT
DATE y y,:
78Yr
DATE FI LED
IN OR
INSPECTION RECORD
OPERATION
DATE
' INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade —z/--
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing —I A
Compressor
Insulation r
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 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
O.K. for Finish Plaster
Sewer Lateral 41Pool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: