0005-262 (AR)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
+Professil%als Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
ti7R07 A 0'713112(
DateSignature of Contractor /S/
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.-lvly workers' compensation insurance carrier & policy no. are:
Carrier STATE RIND Policy No. 046•DWJ33
(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 wprkers' compensation„p.c his ons ofian 3700f 0/ f tR Labor
Code, is fall forthwith comply with -those ovlsloh-s �, >
Date:%i/lc'2 Applicants ✓
Warning: Failure to secure Workers' -ompensation 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. r }
IMPORTANT Application is hereby made to the Director of Building and Safetyt
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 aws relating to the building
construction, and hereby�auth�orii epre§entatives of this City to enter upon
;tle above-mentioned property f • Inspection,p rpose
Signature (OwnedAgertt) Datee/, /..h')
PERMIT#
NBUILDING
PERMIT
DATE f f VALUATION LOT TRACT 106 ,926AO
59 29,15
JOB SITE -
ADDRESS '. 48-744 VISTA PtALOMIRO . �
APN C49-IOi. 006
OWNER.
CONTRACTOR/ DESIGNER / ENGINEER
TD DES,,0r1'DYV;EL0PArt12Tr
SPARKS C31-'3TR0Cn
PO DOX 1716
79-•295 RANGE -101A+ UD4T.ADR.
LAQU A CA 92253
1:,AQ'i.Twft,l CA 92233
(760Y771-1941 C'L". 2996
USE OF PERMIT '
RLES M.FNTAL AI YJ3li ON ,
Y~
SUPPLk«Id EW)[ iLL, TO PERMIT40002-09. r9pl7iPlCi CUSTOM DoUne OUI: T
SUITE (101,08F} 4N LIRU OF STANDARD GUEST SUIT i? (378'SF),
Dl3l'..4IND CONSTRUCTION.
CUSTOM CONSTRUCTION 69100 8F
GARAGE 2I i.00 SN
XYMIA ED COSI- file' CONMU*v I'T014
54",6.40
I'Y-RAi T M&:SIU1!([li/ii.11RY
PLAN CHECK FEE 101-000.439.313 $349,09
CONSTR-fiCTION FEE 101-000-418-000 $43'7. 0
MECHANICAL FEE 101-000-42,1-004 *,A6,00
F. ACYPOCAL PER 101-000-420-000 $42.04
el'umlli a FEIN 101000-•419-000
S'I RONQ MOTION FEE = II; SII3 103-000-741-000 $5.49
OPLADINO FRE Ion 101-000.425"000 920.00
ART IN P'UDIAC.° PLACES = RE SIL 701.000-2.55-000 $137.32
CO M ION AND PLAN CTMOK
t1
$ I,095.44
p`. h LF."73I-`.RF-AATD:I S
UU
$0,00
q YJ ' YMUr YENS :C. UE NOW
y'
S1,095A4
RECEIPT'
DATE
BYf t
/'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
- DATE
INSPECTOR
;� BUILDING APPROVALS'
MECHANICAL APPROVALS
Set Backs _ _ _
��
Underground Ducts
corms & Footings
Ducts
Slab Grade
I E-�� "
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor _
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
r
Exterior Lath
r
Drywall - Int. Lath
Final
Final IPOOLS
- SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
.�
Waste Lines �j�1
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)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
r
Sub Panels ,
Exterior Receptacles '
G.F.I.
Smoke Detectors
Temp. Use of Power
y
Final
Utility Notice (Perm)
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bin
Building. i Safety Division
P.O: Box 1504
' 78-495 CalleTampico s,•
Permit # q CA 92253
La' uinta;
Building :Permit Application acid Tracking`Sheet o
P, Owner /%
shame: S.
Project Address.
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Leval Description:.
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Contractor: P n-t� Y` { i''
Project Desdipnon
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