9809-254 (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
67,4074
ate �l //Z '•� � Signature of Contractor
of
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:
Carrier Policy No.
S t i1.•1?1 xu:Nr) UNIT0007-13111.
(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 t7he workers' compensation provisions of Section 3700 of.the Labor
Cgde, I shall forthwith comply with those proyisio `•'� lj
Fate/j9/--4,1L 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 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 comply with all. City, and State laws relating to the building
consfruction, and hereby authorize representt es.of this City to enter upon
the above-mentioned property for in spection;purposes. f
Signature (Owner/Agent) i e Date• >r;
-. ..
BUILDING PERMIT PERMIT#°NTR°`# .
5b13d!'1-213.4
DATE ' VALUATION Fc9'2Z0a857-th) LOT 55 TRACT, 813
i to
JOB SITE %i�-4lf1.Y% lai'CiB t
APN 8,49-210 04"
ADDRESS ..
OWNER
CONTRACTOR /DESIGNER /ENGINEER
i '
T.D..DSS113.1'
pPAIRICS .M,'.0`rR.Elld1.VN.
RO. BOX 1716
792295 RtANC HO Lel QYIN A Dk. -
I. -A. Qi3:iNTA. CA 922Ti
LA Qid1A rA CA. W253
(760)771-1941- CBL#, 2990
USE OF PERMIT
SINGLt F10MIL ' RM3,1:LING
$;FD, PT.AN.M.- LOT 55, .PCttMI7C WES. NOT ]NaUDE BLOCK WALL OR,
Pl7OLSILAN CRECK FEE RL-DU'MD 756N, FOR, Nf:LFi:.'1 IDLE ISS, rANCE GS
.3 AME Pi, AN TYPE.:
CUSTCi."ti*£ C ONS T'RWCT'ivid 2,635.00 S.'r
3ARA-:f YC IWOR Y 614.00 SF
COST OF CONST j UCT101N
� 220,962,00
yyvv gg''yy yy ��11��, ��.77p ggi�pp �ii gESTIMA'i.CD
SiR�,M.Y.�. ..fi RE, �$11N;�.d7l..�"01,
f.•''C:3T+is'1'Rucfjo.N rt% 101-000-418-000 $1,ntiq�.UU
PL,A.N C',?VE;`'t;.1 101-0 0-439-318 $217.90
NIC-CIfM41CAL tax 10l -OW461-000. $105 *M
ELEC AL FFIE' ..101:.000.420.000 $162.01
UC
PLumBim; M-.— 101• -OW -419-000 $179.25
STRON(y }tuts
GRADING %fL? 101-000-423-000 �ZO.tIo
S.I 11R.I07`1� oc"I 411: E FEE 225--( 443-342 $4,889.27
E\R'1' IN .PUBLIC Pi.AUS '- Pasic '70:1 -NO -'155-•000 SJ t? 2,1 R
$1..113-'1'O?"A.1.. GOMETOR6.JG"3"i(IN AND PLAN CHRICK
LESS ME -PAID FEES
$0.,00
' TO:6-wii.i K.MLl^.3Y.it.1:•&•F. ESS .OU.7 NOW'01
r
tjFGEIPT, (/
DATFJ j l f
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BY ' 1 '
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DATE FINALED
INSPECTOR
✓ (-P ,-, •
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs /I zGf' �
Forms &Footings (� a �—
Underground Ducts _
Ducts
Slab Grade —2—
--
Return Air
--
Steel
Combustion Air
Roof Deck
O.K to Wrap
Exhaust Fans
F.A.U.
— —
Framing �- L(
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath - -
Drywall -Int. Lath 70
Final
Final -2—`(
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
S=�`
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral _
Sewer Connection s
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final q
Utility Notice (Gas) (JL
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
t
Final e_
Utility Notice (Perm)