0009-174 (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. Date
17
14 � 10131!2(
Datei Signature of Cortrac�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) r 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 & ProfPssinna.lc
Corin) '
Oi
I am exempt under Section ' B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION .
1 Thereby 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
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' 001DEW E-AGL,.9 DIS, Policy No. 1+iW449.663.02
(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 I should become -
subject to thq workers' compensation 00112ipAs
pns•Sectio 3700 of the Labor
Code, �,ts�ia}Cfprth�/vitfycomply with, nNs`/ w -
Date:- / / "•Applicant
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
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 entey upon
the above-mentioned p eA; f I spection purposes. /
Signature (Owner/Agent)•=P" • ta•' Date
BUILDING PERMIT PERMIT#
DATE r ., } • VALUATION LOT ' OW9 4.74
• / .. ��
TRACT
� cJ $X 75,6` 9.20 11
23773.5
JOB SITE
ADDRESS
78410 ZFn= WAY
APN
't,W-0269
OWNER
CONTRACTOR DESIGNEREN61NEER
CCryU4CTVr1W
Lk-WIWR C.WLL CyYYTAI M8
PO DOX 5140
1535 SO, OD" MRMT, �_ €- #200 t
'NwPUk:T t3a�i CA 92662
SAW :i3EMIAR:DINQ
CA
92.409
(909)3931 1,6.0(1
C.S.
212(7
USE OF PERMIT
�7 �y T/�j(7(.7
• q'.t e.T d.�f' A•�E'tit'�'r.E D ®Y �•.� ..L.tLiRU ..• ,.I.,
MOA
.
SFD�*PI ANALBR L OT:I'1-PERM1T i OR?3 NOT 1lNC:I,t1D1
060C:1tWAIA.WPOOUDRNTWAYAPPRO.ACFE 5%PLANCIi'FXKEDGE
AUCTION VOR. MULTIPLE ISSUA14CE OF %KME:PLAN TYPE
TRACT CrON8`d'ItUC:'T ON ":606:60 bre
PC32LCIifPAtU Xo0 SES
0AILA.CIEIC.°AR'PORT (SF)' Y;. "' 12406,40
X'Sir"TED CCk4`ror CO..K.SmUCMOR
S 7;X79.20-
C7043TR.UCTION PELF 101.000-418•:000 $909,50
PLAN CHECK FEE 101-000.439-318 $197.21
MECI3A•.MCA1.FEE 101.000-421.200 $92.00
ELF,C'1RICALPEP 101-000-20-000
PLUMBING PEE. 101.000.47..00(1 $161;$0
STRONG MOTION FE • R&SM 101-000-•2417000 $17:57.
GRr` DINO FEF '16).--0002423-000 $20,00
f ��
DEVELOPER IMPACT PI?Z $1;90'],00
� .
C1111
r
MM = tC7!AL C0.99n"W CTION AND PIAN CMCK
$3,442.94
LESS PR&PA1D FV33
;$0,4.10
TMIAL FF-RAIM IME$ DAJE NOW
PA4194
RECEIPT.,
DATE
BY .#
DATE FINALED
INSPECTOR
INSPECTION RECORD
F t
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
12A —""S
Ducts
Forms & Footings
Ducts
Slab Grade
/ 2 t'y ��l-y`
Return Air
Steel
fes) IZ
Combustion Air
Roof Deck
- C�rGy�
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
Exterior Lath
Drywall - Int. Lath
Final
Final
_
POO _S - PAS
BLOCKWAL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
-�� I=.0
Pool Cover
Sewer Connection
12`2—tIA;o Q
Encapsulation
Gas Piping
Gas Test
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)