9907-310 (SFD)Wfl
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
637252 . . B 0291201
-ignature of Cont
Pate ractor.
OWNER -BUILDER DECLARATION
I hereby affirrrf 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
sale (Sec. 7044, Business & Professionals Code).
� ) 1, as owne'r 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
pelo
,;�a ce of the work for which this permit is issued.
(4T I have and will maintain workers' compensation insuranc * e, 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:
Cartier Policy No.
ROYAL MS, CO. (Tj i VvIr. 459=7
(This section need not be completed if the permit valuation is fo ' r $100.00 or less).
I certify that in the performance of the work forwhich 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 Sectibn 3700 of the Labor
Code, I shall f - rth�t comply With t12��` ons.
Date: re
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 hJs
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 oVissuance of such
it, or cessation of work for 180 days will subject permit to cancellation.
perm
I certify that .1 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' t* n purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
D LUATION LOT TRACT
JAN
�,P.6)20or
JOB SIT E
ADDRESS
APN
649-030-02f;
OWNER
CONTRACTOR DESIGNER ENGINEER
OW FIA.1 IS RE53,1PEN'TIAL CONNINIUNTMES
INIC CATE, I US RIESMENT11fid co,�!Kr. INC.
LL
5 PARK PLAZA M 400
5PARK PL.AZA, SUME, 400
IkVTNV. CA 92614
RMN142 CA 92614
CK4 M7?
USE OF PERMIT
.1) - LOT I I 2R RIUMIT DOE-S"NUVIMMUIDE 4LOCKWALL OR
KAN
TIR ACT CONSILRUCrION 1,914.00 Sr-
PaRCIIIII&I"Ac. 11410.00 Sr ,
0AJ:,tAU1-YCAKP(XR.T 483AKf SF
LrI 4"M
1"fl,1V1A :.� IMINS ft T
_J'tj) C0.15T f� TV MCCION
VC]INIFF ME SUMMARY
CIONSYRUCCiON FEE I10i14)00_418_0()C1 $692100
PLA14 QW(CY. 14-16 $1i"I l!9
,vJ4 *(-7'l it N [CAL t!71043 %10 - 412 10 I'll 0
EL -V01 1110A.f.; FRE
4.000
.10 -.000-419,000 $15
.3'TR0NrrMfYrK)W FFF, RRSM. 10 1 -OX)-241 -01. 0
ART IN PUBLIC 701 -00045f-,000
DL7VF.LQYEk IMPAC7 Pa.' 1 "A�17. 00
SUB-TUVAt, COWSIRI [CTK)1W_AND PWXNi CHECK
$1, 5!)A 9'2
LESS, FIRTWIAII)FEES
WIN)
'YOTAOL VCHMIX FEEN HiF, N444Y
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION .
I DATE __TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
0.1 re -o"
Underground Ducts
Forms & Footings
-z
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
/12
F.A.U.
Framing
Insulation
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 .2
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
LIfility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft
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) x--
COMMENTS: