9907-089 (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
C.
` D te��' (� _7Signature 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:
( ) t; as owner of the property, or my employees with wages as their sole s
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 (Seca 7044, Business & Professionals
Code).
O 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
performanceof the work for which this permit is issued.
(Wl 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'rA`jti'!"1J m 0007-333
(This section need not be completed if the permit valuation is for,$100.00 or Ies's).
O .1 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 ag.rd that if l should' become
subject to�the workers' compensation provislor�s. of Section 3/700 of the Labor
Coder,shallorrthVj h comply with those,provls*ons. ti .
Date: I-: r Applicant I
t✓ ,
Warningng: Failure Workers' CC p6nsation coverage is unlawfu 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 3706.1
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, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued BSA result of this application becomes null and _void if
work is not commenced within 180 days from hate 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•authotize representatives of this City to enter upon
the above mentioned: prope rLy for inspectio urposes.
.
vS g ature (Owner/Agent) Date
BUILDING PERMIT PERM' T#�,�
(�
DATE `} � VALUATION �LOT TRACT
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{,!bJOB
SITE
ADDRESS - VIAW;NsMIU
APN 646-322-003
OWNERt
CONTRACTOR / ENt1GIINjEMER+{/�y��
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1/�D`ESIItGNEER
: Si"./Ai.C`i iZ..2 �.wQ1'iai} 1.t4-�J4,+�l.l.li:ia
PO BOX 1716
79-295 RIUN € O LA 't,}"UNT'A DR.
LA tai WTA CA 92253
LA QUNTA CA 92253
USE OF PERMIT.
,0 NOL,f: FAMILTOWRING
4
ur, D -'L T PLAN V3it P10ART D00; 3N•t' T INCLUDE OLO WA L
OR POOL. 75% PLAN ChFiCK,.1ZwLIICTtC3fr! ,vokt MiJLt"rf;ml?
f
"ISSUANCE OR SAM'h- PLAN 1'YP'S. ;
CUSTOM CON ;'1RO&101N - Z283.00 SF
r G.A.&OWCAt2PCJR`i — 48100 SF
,
' ru'STIMATFM COSTOF $w SRda10N,
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1.8-7,632.40':
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PE,rllecg sulvaukAK
CONSTRU&1`iC)iRt,t"'ft 10.1.000-418-000 �941•SO
1'f;ki�iCz1�,4..?�F..: iQI�?39-11
1�;C3�iAtft>�1?ti: f ' lt}i�fJ�i��4�;�aU00 X95:50
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#�1.f C"I'idf.Gelir`Ir. .101-0004 20-000 ia3f;.22
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GRAVID-. 1010U42•MQ1 S210,00
19.�'.tVyl��7;1R�Ry].Ui�'1T'V7d�gIyA�-.�S
11M, 2^5-(00-44S'u85
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A)2.`i•YMPUf3:t C:J LA.Cis,S-'RE&1i:70.1-di()i1-'X5:5-om $219.21
T4WA,L. COX _"rRtJC1!0N A -ND _ IUA N CHFC;K
LESS P.cU.-PAID FEFS
$0.M
'a'Os L PF,`R !Iff #SIC031'1�:N1)iV".
$6,001.68
f Al
hDATE
RECEIPT
BY ! NF
DATE FINALED
INSPECTOR
J.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
-
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
Exterior Lath
Drywall - Int. Lath
elfl
J
Final
v
Final
d _c
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
-
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
—co
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)