9809-255 (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
Vbate 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.
�<) I 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:
Cartier. Policy No.
1.TA.,' 17UN 346-18 UNFIT00073M
(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-Seciio; 3.7.00 of the Labor
Code;.l shall forthwith comply with thoseprovisions.
Ybate: Applicant
Warning: Failure to secure Workers' Compensation Coverage is unlawful
shall subject an employer to criminal penalties and civil fines up to $100,000�1'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.l 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 inspeetion,purposes. � � t'
gnature (Owner/Agent) a Daie`}
A/
BUILDINGPERMIT PERMITCONTROL#
DATEAb VALUATION $240,11 � 269 LOT S5 TRACT 28,839
JOB SITE
ADDRESS J-�YALI.. E :A APN
IOWNER
CONTRACTOR/DESIGNER/ENGINEER
T 0,'DFS ,Trr [AE ` ELOPMENIT SPARKS COAf9 Mi. M ION
IV %, 8() X 1 .16 . 79-295 RAWC•'-:1 O.LA QUINTA DR
`I.A E;rl:+'1N`i''A CA 92253 LA QC1IN A CA 922:,5:9
(' 60)771-1944;
USE OF PERMIT
,FD, PLAN Yat, L0'1 56, l tUtli-'F7C1)d 3�i77 i�vCLi1uB �i GCt WA-L7t Oft
POO LAILA v CHECK FEE Ri33:ED -S% 1+OR iINIU ,'PI!!Lf:: ,ZSS€!r'1:ItCE OF
S A1V1,E A..AN YPIS'.
F'Cl:I$Oii/➢�IL i0 235.W :SF
0,VL QFJCA Vi ORT 470.90W
IIii.7LiNI ATF.D CldY OF CONS.F•RMCMONT
1-40,11 7,110
nmma
,
C0Na►fKUCY1Q,NFEE I0g-000418-000
stxn,06
NfEC,.t M43CAL I" I,O.S ^OCilMi l ,U(tq
$130..50
'ELEC•MCAL FEC 161-000-420-10W
z �►'aa
i�i:UMt33it C SOI-llt3t3-X19-flip
5175.75
597VONI Q MW ION _14i -E - MSID 101-000.241-1100
$24.01
GRADING Y.EH 101_000.423, 0010
$20,00
NI P LASSTRUCT#7RE. FEE 225`0130-443-342
X32.3
A'WF tN`PUMAC PT,A.C;F.3 - .t2FSi1? 701. wO00-255.000
3�ti.Z9.
SUB- F1[)Ts'I L CONS'1•T(MMON AND PLAN
CHECK.
$7,5G?.?4 •
LESS Pin -MD FFIES ,
$0.00
TOTAL E'-:Kii!I!`r F E.LS DUE NOW
$7,54M34
RECEIPT�DATE r, BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
27=c� c�
Underground Ducts
Forms & Footings
< <
Ducts
Slab Grade
2_Z_
� 6/6 5
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap�G_�
�� - Gf cr
��
Exhaust Fans
F.A.U.
_
Framing
�� ��
Compressor
Insulation
_
�C��-
Vents
Vents
Fireplace P.L.
Grills
- Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Finalg
16=9%G
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
�j r -r
��
Heater
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer LateralEET
i
Pool Cover
Sewer Connection
/
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
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
c
4.
Final
Utility Notice (Perm)