0401-120 (SFD)LICENSED -CONTRACTOR DECLARATION
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
6�OGy5 :� I -EC A �4;s &'X104
Date / - 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 inte'rided or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively cgntracting 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.
( )" 1 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 STAI—E FUND. Policy No. 1533006.0i
J (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
I� subject to the workers' compensation provisions of Section 3700 of the Labor
tel' Code, I shall forthwith comply with those provisions!
Date: ii -r'*': 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
i
Signature (Owner/Agent) �' �J 4 .: "�/ . Date l "l (7'�L
" .1. r
BUILDING PERMIT PERMIT# .
DATE VALUATION _13,4 _, R) LOT29 TRACT 29859
JOB SITE
ADDRESS '794Z.5 VIASW �'+iasla.S+.UX3
APN
8 `��%'• .�.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
R IT 1401vffiS 1,LC
1.Ri'+1F:S'mim-8, imc.
PO BOX 810
1425 E. t.1MVF_ ,9rX1 :DM t:'1~
LAQUIW iA C,.A 9 22 5 3
PMEM AG 8,5034
(¢ 02)9,5'1.1656 CI131:.4 4990
USE OF PERMIT
WGLE' FAMLY i"1WF.:UJI40
SPA,T1 LOT 29, PLAN 3FIAC1. PERMIT DOES NOT INCLUDE PODI,
O' A, BLOCK WAt.rI.A OR DRIVEWAY APPRO .ACH
TRACT COWNTRUC T TON 4,04.00 d9?
P-OkC:HMAT-10 903,00 SF
GARAO1YCARPORT 729.00 STS
WrIMATi:D COST OF COlV'NIMIC110IN
243A5&2p,.
1' VIL'3:ll'1ri'9F Ui:TMAIARY
;
CON37RUCTION FTIYZ :101-000.418.000 S1043,50
PLAN CHUX FtE 101-000-439-316
WHANICAL.11Mfi 001.000-491.000 $137,00
FLEt TFOCA9. FEE 101-000-420-000 $13793
F'IAUMSY O YTr& 101.000.419.000
1'i OW0 .M;OTION FZF - RWID 101-000-24.1-000
c73�!`ti�fb'E , h1E 101=000'4.2.3.1100 $15,00
,
Y.1'1W'F,$.tll'''� R IMPACT F'EP' ?t�,4oS.JA
ART ikl PUBLIC 316&CC;'`1- R&;S).0 270-000-445-000. $1080
SUB -TOT1 AL CONS,ir' UMION A�M PI" CIMCK
$1,294.32
LESS PRE, - AM TEES
$0.00
i
I i ,''1 2 8 2004
CITY OF LA CUMTP,
FIMANCE DEI�T.
RECEIPT
DATE �11 r3_,/
3 /` /�
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
—
Return Air
7
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.
77—
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—
J
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Top Out
_
— -
Plumbing Final
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
-141
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
Final
Utility Notice (Perm)