0204-073 (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
x'33670 :6 hic tt30ta2
,Date « ^ 7 Signature of Contractor)
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.
Q_1 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 STATE FUND Policy No. 07132
(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 the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those -provisions.
Date:�!a ,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 enter upon
the.above-mentioned property for„ins�ptection purposes.
Signature (Owner/Agent) �^ �" ' Date %'' ` -,
BUILDING PERMIT PERMIT#
DATE VALUATION $20. LOT TRACT
22 M25
JOB SITE
ADDRESS -M GRAMM Z:OURr
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
iORAH01 1.1
SUNRO. SE t:t3 "'C l�t�►"!'It3 ; ' ' .
77-564 COWAZY.CLUB DRIVn ft127
77.60ACOURI!%Y CUT DIUME15i11'1:.Ei =50
PAW DEM -T CA 91-721.1
MIMDESERT ESERT C"A 92260
(760)772^8224 CILIA 11377
USE OF PERMIT
SM OLE FAv31L'i'.17WM.JWO
3FD • LOT 32 PLAN 3 . F%iA�All�f'T 00.ES t40T fNCUJriE DI.00K
WALLA P004 SPA OR I:1RWKWAY APPROACH, 7AS I4"E hN C'IOX-4 FEB.
IF.E'DUCII'IOW FOR IAUtZ IPLI;K, ISPSLIA14C,'M OF SAMZ PLAY HYPE
CUSTOM Cf,N,�'T12.UCTION 2,400.00 OF
PORCN/P.ATIO* Ie.11-00 SIF
aARACCCARPORT 66100 81?
1PG1'Zft= COST OF COX-FIR11=0H
207X22.70
CONSTRUCTION RX, 101411300-41.&-000 S11017110
PLAN Cl'IEL+K FEE, 101-030439-318 $29135
MJFXPAN1CIM4 V`PIX 101-000-421-000 $1.!10,00
I LI? .>TAIC,P L ?'IMU 101-000-420.000 $I3'I.m
PLV3MMO It'f�.E 1.01-000.413.000 $165,100
S7'RONO It OTIM ME - RESII'1 101-000-241-000 $20-17€'3
C'IR.KOINO 179E, 101-000-423-000 00.423.000 00160
LIEiIZLO,P941 IMPACT IZI. $1,9a7,itG
ART IN PUBLIC PLAWS - ROIL 270-000-445-000 $1944
9-i1D-:' CitiAT. CONTfR':7L1'0TION A14i PI,.AN' C l=C
s
$3,!,09.7s
TIM :I''f21i PAM -TRa
$aoo
' VIS S" ..11 E FEESI DUE 1.Vt1`19'
$3,599,75
n
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RECEIPT
DATEBY
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41, �*--w.�.
DATE FINALED
INSPEC
R;
-� V
I,-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-Q
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_ (j L
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
_ G
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
- 2 -
Final — 2-
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
- a
Main Drain
Bond Beam
_ pZ_16
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
l , O
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool 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
Fbdures _
Main Service
Sub Panels
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: