9907-079 (SFD)LICENSED CONTRACTOR DECLARATION t
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
J
WOW'
r� f
tAafe 7 �^ f nature of Contract
WigNER-BUILDER D �trLARATION'
I hereby affirm under penalty of perjury ,that I am exempt from the Contractors
License Law for the following. reason: f
( ) 1, 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).
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:
O 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..
0 )) 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.,
e. r�.i E v i`�i3' 046 TtC73k'
(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 toer
_wo kers' compensation previslep of Section 3790 -of -the Labor �
Code;,ls sfi fort�hwith comply with.thq e,q ovlsloas;
Date: �%' Applicant P
Warning: Failure to secure W rkers' ompensation coverage is unlawful -rand
shall subject an employer to crim nal 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 ori his
application.
1. Each person upon whosebehalf 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 re reseltatives of this City'to enter upon
the,above-mentioned pt pert for inspection purposes
VSlgnature (Owner/Agent
�.
- BUILDING PERMIT PERMIT # 66 6e
DATE VALUATION.LOTr�q TRACT '25.154
ADD ESS- -f � "i VU ���'M-�.1��.�.�LAI�I:.
APN
OWNER
CONTRACTOR /DESIGNER /ENGINEER
DIS@U tATELO1.1,11 T
.I
SPARKS 4Kc?TplJ(.Trfu R(
t3:i Cs ".i71 i .
E9.295I� 3C::tn[t� €�t� UNTA.DR.
LA QUTNIA CAV2252i
'LA QJ'f:t+ TA. - CA. - 92253.
(760)771-1943 c a.tE V96
}
-
USE OF PERMIT 1
&NGLE FAMILY MILY DWELL.-ING
,
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W611.:.f.: Ott POOL., 7M4 PLAN CHECK FEE RFDQeJTLON F01k'.M J11rfiF°LE.
t` SUANCH ORA11�.:1'.L.AW ►"1719.
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y p1.[0�0]
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!ESTIMATED I�iaATED CD.ST Of CONN+ST.���ia�...� ION
":73'•�.�num
t�yy pp 66d,
P919 -MUT fT IE �a'i�J,14A"R H
TIE
C 0N8*UCi.tt3N F1W, 101 -OW -418-000
LST AN CHKIK R S r Ei:
NZ IECI1ANICAY, FaS $53-50
k1 1liCtiA1;.1"Efi. iQ1 000420.000 X334.59
1D4,UA�1t3iT�49 E�F,� . l03--000.41���t�f�3 bF3�.ttff
T11.c.- NO N[011 ON VM.- R13S±z.r 101-1000-24-1-000 $17.32
ORAD040 V 101-000423-W0 $20.00
1' r-RASTRUCTOREMAM :22571100-443-342 63.897.E
Att'F:IN 1•' ).,LC PLACES • RES.iG W1A00-255-000 W106
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RECEIPT
DATE
BY
FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade
_ _ cl
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
so—
F.A.U.
q
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
lj
•
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
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 2 _
Utility Notice (Gas) jU
ELECTRICAL APPROVALS
Temp. Power Pole.
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main'Service ' ..
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors,
Temp. Use of Power ,
Final.
Utility Notice (Perm)