9902-146 (SFD).c
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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. Date
pat " 3���% 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). .
O 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 Policy No.
w Tx�rFA FUND 035-9 ,'-l^�.30
(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, J shall.f ethwith comply with those�Fvision
ate: 3�y y
Applicant—
Warning:
pplicant 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 atiove-mentioned property for inspection purposes.
/ignature (Owner/Agent) / .9 'Date
BUILDING PERMIT PERMIT
.9902-144
DATE VALUATION $214,941 q11 LOT X1 TRACT 25:189-.A
-3.c.r4
JOB ADDRESS 5"15i.�AR'►M 1 R1AVEf�47E AVENUE'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
09'!'Y.Ir1H+rtC'"ri('•
'il�"(`IATt(t7C't'gXRA'E'1'Q
u t I ..J nu.,td L,.t_ 1Cr •,,,,
11.c10.BOX a i 0
1125 E-. ii't�SlVfR3"i Y DIUVE
I,,A QiJ.lNVA CA 92253
PHOENIX* AZ £35034
(602,1257. 1 6yo 41900
USE OF PERMIT
OR 2.00%. Pl;i?,.'N � J�Ei(:� iri'� [4i OL!(,`1�i3 7��u.t U#t f1�Ui 'i'L4'L:by i ��i�fli�kC i� toiP
SANU3 BLAB T Y.P _
w1' tii1'V1I Qid'.�iiZU%1 i l d G,610X* a
L'OitCLIli �Li'fv 140.00 SF
(JARtVOl:;Yt::rli2POtZ':[' 498WK13}•r
ESTIALAIXED CUST OF CONNTR U' TION
21,4,941,30
FOAMIT PEP; SUMMARY
CO.Nu fRLi ' TJ.0`hJ FEE 101-000.118-000 $1,r�2 fiti
KAN 01 '.K. P hO j Ql•,0f±{S.,�i3� tl,� R7id,h�
hc�1 1L; lrtCfil1 101' t10i):1zi.-0' t') $103.t10
:f:;ias �.;"I'lUCAi.:1'i3L .. 101 -ON -42"00 $158.81
i LL&1JBTNc+F.f; 101-000-4194100 3180.50
;S`l RONO 1t9fiZY N :FrJ r ...1.t.1 , ;LO 101 -OM -241 -ON $2t.49
ORT ADING FEE no:")
sN)7RM'i'12tI4"'PURE N_, h- '?,25.000-414-V 3412 54,794.30
ART IN-PUB1,1C PLACES - R SID 701 -WO -2.55 -OW 287.35
��k' 1Gt-'1 {7t' r�! • a.��� C f f `! I�Ta AN1', $�!A N ORFCK
KK113 _49
U -SS PRL -PAID PUS
TOTAL PERM IT YCES OUE NOW
$6,kn.48
RECEIPT�� !
DAY) r'I
BY/ ,j�
DATEFINALED
INSPECTOR
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck /_
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing - l
Compressor
Insulation G(
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath t
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 9f, r- c
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) . —�a-
COMMENTS: