9905-216 (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
. 6 9rA,)45 S 061300i
Date/e- , 4A 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:
( ) 1, 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
Sal ' e (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
6ontractors to construct the project (Sec. 7044, Business & Professionals
Code). . - . . i
I am expmpt under Section B&P.C. for this reason
pate Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following, declarations:
( -) ! have and will maintain a certificate of consent to self-insLp 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.
' ( "� ' 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
0 mit is.issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
m 1i or NO
(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 Secti on 3700 of the Labor
Code, I shall fo�hWith comply with those pmvisions.
,�Date: A
pplicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an empioyer 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 Bbilding 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 ur der or pursuant to
any permit issued as a result of this applicaton agrees to,A shall, indemnify
& hold harmless the City of La.Q6inta, its officers, agents and employees.
i,Any permit issued as a result of this application becomes null and void if
work is not i 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 inspection purposes.
ignature (Owner/Agent) Date--!:!
BUILDING PERMIT PERMIT#
DATE VALUATION TRACT 253V-1
I I 1 .51179,914.60 LOT 26
JOB SITE ; I I I
ADDRESS &01,-765 GRAND TWvVCMF.AVrAiUr,'
APN
769-056-008
OWNER
CONTRACTOR / DESIGNER ENGINEER
PIrr 1101MES 11C
WC./fUlt'
PO BOX 8 10
1425 E. UNIVERSOT DRIVC
.LA QUIMPA. GA 9225:4
PHOENIX A.Z 85034
(02YZ.57-16% C'BL# 4"0
USE OF PERMIT
8
SNGLE ]FAAWILY DWELL—INIQ
SP`0 - PLAN 1013, LOT 26, -VERMT DOES 140T fl-4CMUDE BLOCK
'WALLS OR 1100L.
CUSTON1. CONSTRIJiCTION1 180.00 SFi
PORCWPA110 18.00 S.F
0ARAGMARPOR"ll' 462,00 SF1
FCSTIMATED COST OFCONSTRIUCTION
179,914,60
V CRM 1T Fll,E, S U hi MAMY
CONSTRUCT-K,11N MRS lot-000-418-wo
NIECRA,:�PCAL f-EiR SIM.50
]WECIVRICAL FUs' 101-000420-000 9143,04
PLUMKNOFIFIR .101-000-419-M $136.50
S11?0NOMOTION FrEF - R)Eflff) J01 -000-70-W, 1117.99
Oki-UHM ME t01-000-423-000 S20.00
wmmvtt )cvjw-_ jrqz .225-00OA4'�-14.2 S4,01i.74.
WfIN PIAMAC.0L ACEN - RES IT, 7014010-2 55-000 $ 1 t)%'79
C'0N',rK(R1JC MONAND PLAN CRECK
$6,137.01
LESS PRE -PAM FEES
$0.00
t4w
BY
DATE FINALED
JINSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade _42 01: 4!�L_
Return Air
Steel
Combustion Air
Roof Deck 7-07-2q
Exhaust Fans
0. K to Wrap —,?I*
F.A.U.
Framing 2
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath -,W-
Drywall - Int. Lath 2- V-- -7-1
Final -2-37 71-1
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 11"el—f f 10?57_�
Heater Final
Water Piping Z_/
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 (2,
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final ZZ2_75i4_�* A917
Utility Notice (Perm) /0 -:;2 5-- 2_1