9905-217 (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
. 04 U) 'Professionals Code, and my License is in full force and effect.
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=) c) License # Lic. Class Exp. Date
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69(W3 0&30120i
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Z r— D aif�e 5,:/l Signature of Contractor
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(D.
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OWNER -BUILDER DECLARATION
W : LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
F-, cL, License Law for the following reason:
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Z 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structu re is not intended o i offered for
sale (Sec. 7044, Business & Professionals Code).
as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C�) I am exempt under Section B&P.C. for this reason
4LO
CJ Date
O.N Signature of Owner
WORKER'S COMPENSATION DECLARATION
CL
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CC I hereby affirm under penalty of perjury one of the following declarations:
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0 1 have and will maintain a certificate of consent to self -insure for workers'
X . LU .. � Compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J_ performance of the work for which this permit is issued.
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< 0 )/1 have and will maintain workers' compensation insurance, as required by
d Secion .3700 of the Labor Code, for the performance of the work for which this
un! I<-- -
M_ permit is issued. My workers' compensation insurance carrier & policy no. are:
It' Z Carrier Policy No.
00
STAT6 FUNE
(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
.tll
Cocl�-,"l shall forthwith comply with those pr�ov��ns;.
'Date: A Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
�hall subject an employerto 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
foT ra 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
wh - ose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicatoin agrees to, & shall, indemnity
& 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 1,80 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 inspection purposes.�
S' nature (Own6r/Agent) Date
PERMIT #
BUILDING PERMIT
�Yfi-j 9- 2 t, 7
DATE VALUATION $179,914,49 LOT 27 TRACT 25,00-3
JOB SITE
ADDRESS '50-745 CRANG TiLkWASE AVWNUE
OWNER
CONTRACTOR / DESIGNER / ENGINEER
p 'r cf, %�4 Q t, F,C
IRT." IIN V17MT*AAr-'NTS PIC "VT
4� #A 0, . -it I
POBOX 81.0
14125 E. 014M. RMY DRIVE
LA QUINITA CA, 922�3
PHOENIX A7, 85034
C B L # 4,9.W
USE OF PERMIT
S, IN(A.-E FA MILY -DWRLIANO
SIM -,PLAN im, i,ar 27, -POINIATDOE-3 NOT JNt-_JXDF_i BLOCK. -
WALLS OIR PWL, PLAN (1-03SX PORTION 0b'J;'UB RJEDUCL-'D 75% FOR
9'1FSSLhVNCE OF' SA
'NHY Trfl QMR PLAN TYPE.
CU 25IN"" M 000 N.3 11IRNE CT 110 N Z A, 90.00 3F
POI(CH/pATIO 78.00 3F
402,00 SF
le-STIAAAMM COST OF CONSTRUCTION
PERMIT FEE SUMMARY
CONSTRLIMION FRE 101-000-418-000 S919,50
PT. AN Ckff CK FRY., 01-000-439-318
M`X,T1AN1_C.AJ1 FEE .1-01-000-421-000 $98.0
FI,"- TRT,0ALVr-St 101 -NO -420-000 514104
PLUMBING RX 101-000-419-000 3156.50
,,W),IoNa MMICWN r -Mr, - R13,51D O)II-MO-241-CM $ ! 7199
OR AD WO RM
t N F R A 8; F I t 0 C , E V F, B 2125-000-443-.�42 %40)-24.74
AR'I'I-N PU13LIC PLACFS - 11ESIP, 101 -NO -2554M $1.99,79
SUB-ITYrAl, CK)NNSTRUCTIO-N-4 -AND PLAN CHECK
$5�769.�10
F, SS PP
IrE ly - Ark I D FE S
1110.00
TM AL PERMITFERS OUE. NOW
$5.769.30
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
3.
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 9 e—
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck -7 -;;Li; AW
Exhaust Fans
OX to Wrap
F.A.U.
Framing
V -
Compressor k
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath E3E
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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 (e
Pool Cover
Sewer Connection - ------ — 46 -
Encapsulation
Gas Piping
Gas Test 2_0
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power -Pole
Underdrourid'Conduft
RoughWiring.
Low Yoltage Wirinig
Fbftrer�
Mairf Service-'
.Sub Panels
Exterior Receptacles
G.F.I.
Smoke, Detectors-- 7
Temp. Use of Power:'
Final.
C1 "'AlYL
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