9907-090 (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.
1 `License # L'ic: Class Exp. Date
hl4f�il ��
0705 lW
ate / T Signature of ContractJ_r=
oo
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).
( ) .1, 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 3700,1 of the 'Labor Code, for the
performance of the work for which this permit is issued. ,
(t�)59l have and will maintain workers' compensation insurance, as required by
Section 3700 ofthe 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.' ,
(This'section need not be completed if the permit valuation is for $i00.00 or'less)..
( .) I certify that iri 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 l should become
subject to the workers' compensation provisionsof-Section 3700 -of -the Labor
Code, I shall forthwI�th comply with those provis ons. t
Date: / �.� �,.?pplicant
<.w
Warning: Failure to secure Workers' Compensation coverage is, unlawful and
shall subject an employer to criminal pe a ties and civil fines up to $100,000, in
addition to the cost of compensation; damages as provided for in Section, 37.06
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 caricellati6h.
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 qr p rty for i sn pection purposes.,oe
Signature (Owner/Agent) ` / Date
PERMIT #
'BUILDING PERMIT,��7_r„ai,
DATEy VALUATION $243P79 3P79 x.40 LOT 3,q TRACT 25354
JOB SITE
ADDRESS /7"851riA�iELY f t�
APN _ t
646-322-t>W
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
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SP ARKS Ct: N1 91i" UCC. 4
TO t3C3X 17'.t6
751UNC✓HOLAQUliNi`t�i:l�t7
LA QUINTA GA M53
LA. QUtt+> ,i'A L.A. 0153 -
t
(700)'771-,194 p Q31A :996
USE OF PERMIT - °-"'^ •
�i`Nt�t.,�
6FD LOT 39. PLMV4 •,PEW&r DW; .t OI i:;1+;,`s`:i'iL,f -BLOCK WALL
OR POfJ•L. 75% FLAN i;HMG;.b; M IZF�US"•�'i.C+l� �C7fi C�U.C.,i l,i� l � � .
1S.Si:7AMt ORSAME PLAN •CYPF_ ^r ,
CUSTOM CON'S ITUC:f ICON 1Z5b6 00 SF
GAJ A0 Y0,A1%E 0RT 6,5:+.0 o Sr,
amioria �i�i�a i:,'tiZ1 �S'3: ✓WC _N' a�a�%� iZI
"1A.793.40
VERMT FE
G+; NITt"F:(JE TIONFES!i 3Qf.�C-41:$-EH3fJ S:i,€f3$. lti
?WN ClifficeiK -RAV, 10-000-4-39 418. suum
• M=LANlgCAL i FX- 101•-000-4c21-000 -
rt,C~�,"I'%MAL CU ' - 101-000.420-000
PLILM410NO FEE EU:4 1100-4f -000- S i 61.2.5
S'f°RONC MOP ON FH , RE!, if >
91R,faD,:'.1401.EL: $20.00
l
INF z �3c to ii 225-000-40-342 34,W -Al
ART IN 3'UI; 1C VL ACES - .RBSE 701-000-255-000
'S -TUT T, Cr12°1 �';I3.4J4"3`tc�r� ��,Ng� pG:l1CV C°:�IIC
$6,'79(), rJ
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ti,_`r - �'�•�#J,4\LPQ3iL MI �B. FEES 0J4. CANO i�Y
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RECEIPT -
DATE..
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
of
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
_ 2 _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
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 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
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 dui �t
Utility Notice (Perm)
COMMENTS: