9809-251 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am 1icensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Busines§ and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
?4(171 MILO
tib ` l j '
ate ° 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
icensed;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, asrprovided for by Section 3700 of the Labor -Code, for the
performance of the work for which this permit is issued. t
�() 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.
STATE FUND 046 98 Uld1TWO733,3
(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
workrs compensation laws of California, and agree that if I should become
•subject to the workers' compen§ation�provisions of>Sectian 3700 of the Labor
Code, I sFiall.for7hvLrlth comply with those p oyis'4ons.,,`"�.
ate: lU�L �JJ Applicant = A\
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
construction, and hereby authorize representatives of this City to enter upon
thZature
above-mentioned property for inspection purposes. !
'..� '° fir
(Owner/Agent),,,, J fh� r �ate&3
PERMIT#- CONTROL#
BUILDING PERMIT
e,�_� >E gm
DATE VALUATION. LOT. .LOT. TRACT:, Y�
JOB SITE da
ADDRESS
APN
64?3-21Q-042,
649
OWNER
CONTRACTOR/DESIGNER/ENGINEER
11'v" 1'
SPARKS C01S.IS DUCT ON
P.0. l 0X 1716
79-293:[t 4.I C140 LA. QQH47A. E L
!;A t)•f INTA CA 92253
LA QLl1M'A CA 92253 - .
(760YM-1 41 CMI #. 2996
USE OF PERMIT,'
' y1IdCri_;E 1^';fAtUf:i'1..�' IWh;j'.J:,lidt'.f
SF0, MAN E1, LOT 52, Pri-RI'MIT WES NOT I.NO L10913LEX WALL. OR
POOL PLAN CAIFXK FPY, €?IrDtJCV0751A FOR AWLTIP-'irk fSSU AM OF
SASvY}' N ` KA'ffE, -
CUSTOM CONIMGC,1710N x.,631.00. W
100RC1='V1:1 TiO - 267.00 SI'
GAG AOMAW-IORT' 6,14.00 S.
a uY g.11vJ EA s .%�i COST OVCONS UCT"�lir
� GiZ;Ir�::�f�
PERMff .FES: SWUMA Y
1
CON -ST UCT( 7N FE -, 101-000-418-000 _ ii,ub .lSa
E1 AN CHEM FEE 101.-C00-439415 $217.90
A4f~clitwfCAL FEE; Iill.-o00-42.1.-000 �.iOS.€tif0
6Lk(—,1"1 0AL FEE 1,01-000-420-000
i'1.1JM81�3ti Y E (01•-000419-000 $179 25
STRONG i4S )TfcaN.F ,-,RFSTD 10:1:-OM241-000 $12"U)9
01'viMOG FEE 101-000-423.000 $d�.itfi
1NFAA39'R1:70'TVRC VEE 225 -ON -443-342
lAWI:' N :€ LVBLJC PLACES - RFS.w 7.01-4 25S-wo
SUB -TOTAL CC3? STRUCP.QN A.cND PIAN CNuCK
LESS..'PRE-PAID T"TES
S0,00
f3Ti6. $'8�`R1%JT FEMME NOW
56,960.65.
RECEIPT r
DTE —7 � � [
By X '�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backsr
f�_�
��
Underground Ducts
Forms & Footings
C
Ducts
Slab Grade
Return Air
Steel
Combustion Air
_
Roof Deck
3 .Z
Exhaust Fans
O.K. to Wraps
�A/l-
F.A.U.
Framing
I,<
Compressor
Insulation>
c
_
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
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Electric Final
Waste Lines �� �= �f
�L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
10
AA
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
t
t
Final
Utility Notice (Perm)
_