9809-245 (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 f
ate, Q P.AA Signature of Contractor"Y
OWNER -BUILDER DECLARATION P
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
DateSignature 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.
(y) 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.
S3: A"...6 FUND 0$0s93' ii'�tIT000,338
(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 tle workers' compensation provisions°of Sec 'n 3700 of the Labor
Code, L sh II forthwith comply with those provisionst
v6ate::� -5 I Applicant i
. .V,
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,1 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, 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 fog inspection purposes.
kSignature (Owner/Agent)- / n =:-Date
• v
PERMIT # CONTROL #
BUILDING PERMIT
!►�c�,="24,5
� �q q
DATE VALUATION 2- 8, — 00 LOT �'6 TRACT �
329
ADDRESS 1 Nti�i �J i t �7 T:A► JOB SITE
APN 6 -no-042,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�.1. GESERT 01 WIl,.OPME11i i
S%'ARKS CON53 rR11c,1` 0IN
P.O. IXYX X716
QUI[1V rA, U1t,
LA.QU.1NTA CA 9225-31
1,,.kQwtolik (A. 92253
(160171-1941 CTL# 2996
USE OF PERMIT
S1NGLR J,''AN41:LY DUTLLINd
57). T iAN CI., j', 07' 4e, id1K[[2. I I` 60GS 'NOT NCL'U E BLOCK WALIL OR
€'4:►U;:. F'l.AN �;r�:�:1�A:�; iiElaCta #�i� 'f��,�n i�a12. �d3if:L'i'�1�1:� laSUl1N•C.A� i7i�
$.AME'PLAN '11YPF,
CUSTOM COid;Sr l RVCTION 2,635.00 SG
PORCIWATIO 261.00 3
GAid OWC'.ARPORl' . 6J.4.00 SE'
M1 MT..C.9 t'OXY O:1i C011,dSTRITMOIN
220110VI ►:L: 19
K21NUT FEE SUMMARY
C0N..TrftUC'." 10N FM 10.1-ULA-4.18-OGU l.t►6 ,cn�
kN C; -ITO E. 1.�}1_,.OQ;, j3??- !i? $217.90
MECHANICAL F.Ce 101-000-421-000- $105.00
.
EL£CTRI.C�%L FEE 101,000-120-000 $1616.01
PI.T.WING FEE 101-000419-000 S179.23
STROING IVAOI1 r )N, '-ITT-'M101-OW2,41-0011 522.09
GRADING F'.Scl 101-000-423-000
11d1-1ZASTRUC,1 URE FIE225-000-443-3,T2 " $.€0s.27
ART 1N PUBIAC PLAICES-.RE810'701-000.255-000 51012.13
511B-TOTAr, G911TCII0TI ANDPLANCF.11 C6p.1*5
I;.L.]iJ �yltiF-PAI:d ITla
g0,00
.1(3 SAD,. 14 ER MVf 1<+ C.1`'3..D1G E NOW
�l9y�it .6
RECEIPT i j
DATE ) tf
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Z 3G -
Return Air
Steel
Combustion Air
Roof Deck
O.K to Wrap7–
Framing3=
2_
—
_
C
Exhaust Fans
F.A.U.
Compressor
Insulation
`6. �Cr
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
_
Party Wall Insulation
Condensate Lines
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�Z=3=
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
I ! L'3'
/•�
Pool Cover
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
Final 6
Utility Notice (Perm) �0,2�=0111