9908-037 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 U)
LLI Professionals Code, and my License is in full force and effect.
=) Cq Licen c. Class Exp. Date
r— CY LO s 45
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/Date JrA
Z r Signature of Contractor
0
r- I.— C=� OWNER -BUILDER DECLARATION
_J (-) (D
W r*- I hereby affirm under penalty of perjury that) am exempt from the Contractor's
a- 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 structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
ce) am exempt under Spction B&P.C. for this reason
LO
N Date Signature of Owner
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0)
< WORKER'S COMPENSATION DECLARATION
2 Z 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'
k Lij Y= compensation, as provided for by Section* 3700 of the Labor Code, for the
0 _J _J performance of the work for which this permit is issued.
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< C) T_ ) I have and will maintain workers' compensation insurance, as required by
b 0 Section 3700 of the Labor Code, for the performance of the work for which this
CY) permit is issued. My workers' compensation insurance carrier & policy no. are:
Z CarTier Policy No.
STATE FUND 035-98-12A0
< (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
VYs b*6ect to thfi workers' compensation provisi6ns'of Section 3700 of the Labor
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de, h comply with those pro sibns.,77
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a e Applicant— -,77,
Warning: Failure to secure Workers' Compen sation 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 cohditions and restrictions set forth on his
application.
4 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 e on
/ i — p
the, above-mentioned property for inspection purposes,
/Signature (Owner/Agent) Date
PERMIT4,%)R-4137
I L D I N Q P6 RMIT
DATE VALUATION LOT TRACT
JOB SITE _50-820 GKAND 1HAVC10SE AVENUE
APN 1169-050410Y
ADDRESS
I
OWNER
CONTRACTOR DESIGNER / ENGINEER
Rli'IN I -TSM, IWNS, INC.
RIT IN VE79MIENTS, INC,
1425 E. MVERSITY DRIVE
14155 E� UNIVERSITY bW1V E
PHOENIX tV 8,5034
PHOENIX AZ 8_5034
(602)257-1656 CaB 491A
USE OF PERMIT
SINGLE PAMILY OWELLING
St,U- IU171., _YLAN 550 AK FtItRMIJ Mft-i NUF XN�.:LUL)h U.V,(KK
WA1,L OR P001- 15% REMICTION ON MAN CM.CK FEF FOR. NIIJIMPLE
ISSUANCE30F 3 -AW PLAN TIM.
cus,rom CONSTM=ION 1,984,00 aF.
PORCIPPATIO '77.00 ST,
0ARAGEMARPORT 431.00 SF
ESTMATED COST OF CXW3TRV4l7f ION
10,044.50
)PUMMIT FEE SUMMARY
CONSTR=ON FhC 101-000-418-M. "70.,�tl
MAN C1W.CK FEE 101-000-439-318 $_"l I I
NMECHAMCAI, FEE 1014*04.21-VK) %0.00
&LE011CM. FEF iOl�OW-420-000 $136.60
PLIAIMM FEZE- 101--000419-0W 5 15 7� 0 Or
STRONO MLYTION FEE, - MfD 101-000-241-000
GRAWTO FEE 101 -W"23 -WO
Afrf IN PLIOL"fC.PLACES - n-;3Jr,'7014KI0-255-000
OE, VF-LOPER IMPACT FW
J
el
SUB-WrAl. CONSTRWMN AND PL&M CHECK
$1,863.3'1
f' I
L SS PfM-P.A1DFE'fiS
$0.00
TOTAL PERMIT PEFS DUE NOW
S3A63J.2
Aq,11
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
92- &!��:
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
Combustion Air
Roof Deck
0 41 L
Exhaust Fans
O.K. to Wrap
F.A.U.
-e
Framing
Insulation
91, - 1? 11 A�WICA!�_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final z
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Foofings
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
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final ew IA��—
Utility Notice (Gas) cr/
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: