9907-191 (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
6372524 B OW29120(
Date gnature of Contractor
OWNER-BOILDER 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
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).
( ) 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.
(py-1—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.
TITC
ROYAL CO, OF i
(This section need not be comp leted 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, I shall forthwith comply with those provisigns.
Date: 1—&..1�20kpplicant_ =1W A—
cz,."
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 condition's 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, 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 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 inspqction purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT
DAMN 06 20ORLUATION - S.114t"3 .0t) LOT
JOB SITE
ADDRESS 79430 MEW WILLOW ST REET
OWNER
PERMIT #
."07491
86
APN
TRACT 2113601-1
'649-03"20
CONTRACTOR / DESIGNER / ENGINEER
r
CAMUTS RTSI-EIDMAL C101-00"UNTITIES., MIC C1,11.1rMILUS RESID.:W111"Ll, 'COMINROTIMAES,
5 PAKK PLAZA, SUITE 400 5 PARK PLI-aA, SUI,'I'E- 400
IMNE CA. 926114 IRVINE CA 926014
(949)251-6100 M1111 -5072
USE OF PERMIT
SINGLE FAMILY DWIRLOING
SF—D-Lf,'fTS6PLiWjZR Pfilkkf(TIDOES NOT INCLUDE BLOCK WAU OR
IVUOL.75',1�6 PL.,W C RFI)UCC10N APAAW I -'OR IVILILTiPLF, 31JIBNiln'Al.
IMACT CGINS)TRUCT1014 1,91"M 3F
PORCIMIA7f 10 00.00 SF
(_3At(AUH"A,A1.kP0fG' 483.00 Sit
1
1E,VT
PERIM1T V *r),E SUNIUAIRV
CIONISIMUCTION bl�h'
101-000-41.8-000
S692.w
PLAN CRYOK F -FF,
X03,04110NI'CAL MOE,
1.01-000-1112 I-ery
$ 15 61 0
a WIT'RiOAL FfIE
I0 I -WO-412"'00
1454,00
SIV, 0WO M 0'r I ON V FT - RY4S 10
10 1 -000-241 -MO
5�11
I fY
Airt IN PUBLICPLACE8 - RES11" 70i-000-255-000
.'.) .
0EV0�0PPR
-4
S1 _11( .1 HP
s rR' -Y-11A G CCNETZRI W7 10K NNO PI -AN C CK
$-4
T FQ11 P]U;_
TUf AL 11 CIR MIT MEN 0 VE INOW. I s .3, 1 s 8, "
RECEIPT DATE BY I Dyfl I INSPECC
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
SetBacks
Underground Ducts
Forms & Footings (4
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K to Wrap <9/—
F.A.U.
Framing
Compressor
Insulation
nts
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 79-2— 25— :�itS
BLOCKWALL APPROVALS
Steel
POOLS—SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. 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
Sewer Connect on V -0--t-2_-- (54—
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit 04
Rough Wiring —cp.-2
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: