0009-175 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
„Ohapter 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
141 / , 10/31/2(
Tvybate Signature of Cc t al c r"
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
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 06LDEN E.A01.E P4.91 Policy No: NWC-544068.02
(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 th�e wor ers' com ensation visio s of Sectio 700 of the Labor
Code, l sh fl fort& h comply,with a pro Is&oos. �-
Datew
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
fora 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..1 agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City t/ent r upon
the above-mentioned pr=opeTwf-Trlq ectiory6urposes.Signature (Owner/A entj% -"� Date/r✓
BUILDING PERMIT PERMIT
00 ��"ry�
DATE VALUATION LOT TRACT
06 $173479.20 1.2 ` 23773-5
JOB SITE
ADDRESS 7F3` W 7.E yM WAY
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PO BOX 5140
1535 30. "D" STRUM MZ 9200 �
NEWPOW BRACH CA 92662
SANBEWARD11140 CP. 97A OS
(909S1R6scn ck37# 2.12o
USE OF PERMIT
OFN= PAbAff Y DW.M1M '
3FDaPL.ANALA I T:12. P$MIT DOES NOT INCLUDE ,
11Y.GTCKWAL WIPO DRIVEWEt.Y Af'PROAC14.7,S% PLAN CHECK FEV
REDUCTION MR. MULTIPLE ISS WANCE OF MMX PI" TYPE •
TRACT CONSTRUCTION 3..000100 SP
POP.CH/PATiO 28.00 Sb'
laAR ►QWCARPORT (SP) 12,400.80
E 1`IMAI "D COSH' OJ'' C01VS7'RUCrJ.0N
PERI&liy' FER UAgd- aRY
CONSTRUCTION FM 101.000-418.000 $903,50
PLAIN CHECK PEE 101-000-439.318 $187.21
M ECH1WICAL FEE 101.000.421.000 $92.00
lrL ,CTRiC,AL FEE 101-000-420.000 V5e,16
PLUIJiiItAiO VY -i1 101-000-419-000 $162,50
MONG NOnON IEE - RE,SID 101-000-241-000 $17.57-
`R,lei. INO FIX, 101-000.4215.000 $20,40
DE41EWP.Gr'R IMPACT FEE U907,00
Il *7A
ar
�sris
SiTB_*i4TAL CO24:i'1RUC" ION AND PLAN CI -TEM
$UA42.94,
15,W PRF' -PAM F
$0.00
TOTAL ]PMW r! F EES Dii1><' NOW
402,442,94
RECEIPT
DATE``
BY e
DATE FINALED
INSPECTOR
00,
' INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
l2jCr,%
Ducts
Slab Grade
2% I L/ �(r9��
Return Air
Steel
l 2j it')Combustion
Air
Roof Deck
Exhaust Fans
OX to Wrap
�- Z� C2�`-0�
F.A.U.
Framing
Insulationl-ID
S CQ�d�
�F�
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
(.0('
ct_/(.0—
Drywall
Drywall - Int. lath
_
Final G �q_a
BLOCKWAL PROVALS
Final
POO $ 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
I��Z►,.� (�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
iZ,� c X' 0
Pool Cover
Sewer Connection
Gas Piping
12—
Encapsulation
Gas Test
Appliances
Final
Final42
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: