9907-076 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions o�'
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
040"4 33 ,� v
is
Date � 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:
( ) I, 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).
( ) I, 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.
61 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.
«l'1 AITU r'Cf itis illef -ij0 %�'�+°r3
(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 compensation provision ; of Section 3 00 of the Labor
Code Sall fort with comply with those pQSio`s�Date: Applicant
�farning: Failure to secure Worker 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 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, 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 complywith all City -and Sate laws relating to the building
construction, and hereby'-authorizerese-n�tatives of this City to enter upon
the above-mentioned property for inspection pyrposes.-,
BUILDING PERMIT PERMIT"O7
i76
DATE`" [1 1 �/ VALUATION "&240,117.10 LOT 43 TRACT 28912
l ! � ! f
r �
ADDRESS 49-783V I�� Lalti QUIS :�TTt%R
APN ("69-210-06
OWN�E+yR'�
CONTRACTOR / DESIGNER /ENGINEER
1*
SMIRKS CiRSMIRLrTIONI
PG BOX 1716
79-295 RANC-1101 A QLAN TA M
LA. QUIN,1'A, CA 93253
I,A QU NTA C.A. 92,253
I7&W71-1941 C131A 2w)
USE OF PERMIT
S1'ASf.;i.L , I=Aivvi:ILIV CiMBI... ING
Ski) - 1,0f 43 PLAN MR - I1'r"R'WI'.i DOES NOT INCLUDE BJ.C►Cis. WALL
9R i'(.1(X. 7SP/o PLAN Cii.EC K V:t313 t1E-J UC -r.I.ON H Ult MLILI x'Irll.ii
WSUAiW.:E OR SAME PLAN TYPE.
IiSTGA -1 C%'NSTRUC"'T ON 29224.00 r1,
i' OJCcfii%PXT10 235.00 fi'
GARAOWC'Al'tPOWY 470.00 SF
T'.CR11UT FEE SafMMARV
CON-STRUF "J 1ON FEE 101-W-418-000 $1> 13:+.5►0
PLAN 04r?3 C K JFFE 101 -0(10 -439 -;SIR $232,24
;N1LCi1A1VlC AL iF'Eka" .10.1-000--121-000 $130.50
MUMUCAL FiEg 10.1.000-420.000 $169:24
P1 UMBING FEE ,101-000-419-110) x175.75
g?'It NCa A9�J P1t7Zd r - !� Srn !9!--000-2a?-(X)0 $11A.01
MUXI 73'NG r—EE 101-000-42-1-0001 $20.00
1NF-RAST.E'1iic;'itiMI. FEE 225-00044X342 $5,332.31.
ART R4 PUBUC PLACES - HSS J; 701-000»255-OfJEM �3Sfi y9
St t3-1VOTA!, CnhlMI Uc"I ONN AND PLAN CNWKW
;5!'-t*},AT12iP$0.00
` Orl'AL, PlLRMil') F M1,S DUE NOW
S7,,15%7.34
f
RECEIPT
DATE
BYr,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- -
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_ Q -tot
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
-
(,�
Compressor
Vents
Fireplace P.L:
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
vow
Party Wall Firewall
Exterior Lath
_
-
Drywall - Int. Lath
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final - �-
Utility Notice (Gas) 4
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 d crJ
Utility Notice (Perm) - �-