0002-138 (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
674074-1 . 11 07/3102(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from m 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. My workers' compensation insurance carrier & policy no. are:
Carrier ;,T,k,,Tg InjgD Policy No. 6D46-900 335
(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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT"
Uf34D2-:1.38
DATE 04/4'K4/20CVALUATION $240,117.10 LOT 39 TRACT
JOB SITE
ADDRESS 48•-210 VEDA. CAIM
APN
649-IM019
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ID 71ERERT DE Vla,0144 EN T.
SPAM CO'NSTRCiC17014
PO BOX 1716
79b29S Idl+ ICHO LA QYJTI XADR,
IAQUIRTTJG CA 922x3
LAQU04TA CA 92253
(766)-n i ^ 13A 1 CBLA 2996
USE OF PERMIT
FOU FAMILY I2t •LL.f14C1
i
STPD-IJOT 39 PLAN 920R-'PEPMIT DORS'N'(Y1 1NCLUf)F 8I.,OCK W A;LI.R OR
PO01.iSQ,6 PLAAi CFMC K FEE 1 ZDUCTION FOR. MULTIPLE ISRS ANCL OF
SAME PL.11W TYPE.
CUOTOM CONSTRUCTION 1,924,00 OF
PORC WPA^► IO ; 135.00 SF
GAItA.OWC.ARPORT 470,00 3F
F,STMXM COST OIC' COWMI MON
240J.1.7,3.0
PEW Ind' F SUMMARY
CONSTRUCTIt311.4 YKE 141.000.418.000 Lt1,133.00
P KN CHFICK FF;Ir 101-00"39-319 $232.24
MECHANICAL F BE 1011-,00&421-000 $130,50
Ei..FWTRICA* L F M, 101-000-420-000 $16y.i4
-
PLUMBING WE 1411.000.419.000 $175.73
S1TR.ONO Af OT1014 FFE - RESID 101-000-241-000 $24.01
GRADING FEE 1 M -000423-000 %20104
OEVFLOPJ?R IMPACT FEE I$I,9n.00
ART W PtI'wC PLAMS - Rmgw 701-fi0o-755.%900 X350,29
tlt'JT34Ci7PAL t"E3AISAl'�.%ftw1TCJN AND PLAN C21Ec`;:il;
$1,,142.0:1
LESS PRE -PAID Y?1±'ESt
50100
"TUTAL. MMM:IMX8 DVE NOW
$4,142.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs��0_5
Forms & Footings
��
Underground Ducts
Ducts
Slab Grade
<C." AP
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Waste Lines 7
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
�� �—
Pool Cover
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
Utility Notice (Perm)
COMMENTS:
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.•}a
U1 ••i-1UJt-7fi,Us
Date ®o 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 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 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. My workers' compensation insurance carrier & policy no. are:
Carrier,`iii; a `S. 4.^ a Policy No. �tlfj iii ��
(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 -go as to become subject to the
workers' compensation laws of California, and agree that if I should- b7ecome
subject tolthe Workers' compensation provisionsofSection-3700 of the Labor
Code, /shkll forthwith comply with those pvisions.
Dater ' UJ 0 Applicant--------
Warning: Failure to secure Workers' Compensation coverage is alawful 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 Quints, 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/aut o ize representatives of this City to entx0r,
the above-mentioned property for in�.tiofipuu� oses.
Signature (Owner/Agent)_, — -- 4 Date
BUILDING PERMIT PERMIT#_
= �) EH3�'u!-x i?t
'ATE �'; 29306
VALUATION` LOT TRACT
JOB SITE 41i-LRI) t.§ }9 k;ik ..ilcu
APN 649-100-019
ADDRESS
OWNER
CONTRACTORDESIGNER / ENGINEER
CC
ll/ Rq
d1u j'CA 1.
1}ii #yi-))C 17; u
i!?-,� 31lttS�il.i11J LA i IIANii t1 llR_
1,A QUINTA CA. 92253
LA (1lJiNTA. CA 92253
t74�;1771-tgdl (1,141,ff 29%
USE OF PERMIT
biNO'Lh FAMILI 1JW.ELLINi.i
�
>C LN: W I: A J. .1" r -4 "i2wk- X*:&%,NIL JlA..0JZ,0 1Vl1 A Ai Vi..L C,illl-: CJl.i.d\.l'A. 'iH t<R. Y,.wl T. -;K
IN OL PLAN C'HL0K.FIih liEDI9,3'10N ivti11.7t.FILE I.SSUANCY, c•rl
1AME 11, AN TY1•;k;',
AVi Al iu
e,AXA4s&k:iUJUIOKV 4'A).00 ah
r l Y.1, VIM!) �! l: �6i.r•i 'tt.Is ', rK,�i it..f•A N.?.l.i i i<�
.4`'0� a A 7. Y0
!f'ERMVi FE.E. S$1IMM.AWW
Ct )NSn RLICT1ON }• EH 101-000-418-000 S 1, 13� 00
►�iyy, d iJ r.A' i� C"ti 3 F f t-l//iyyfl1��l{(1���4 t��-lI`►/nl�/i�t $I -Al y,L
pp /(�l
eYSt1€ AIA: +;t •.l fA. L 1:L X01 000-4211,000 $1 (r 5f1
i;L&-.c;1' O AL Pb [01.000.420-M $109,24
PLUMB (NO F0-- 101 -VA) -41'9-000 $17131
1:Tir<1iJt: iL!t)TrC1N ^r't . t7CT1! illi-nitfl-�tt't-41()(1 $^a. at
. s11 t\i�3I;G 1 t. ;f11.OVi3• •�2''UOJ $ i ($01
011V#!.L+ 900. $➢ PACT E LAi s0oT.tA)
Aji:r iN ZJUaI'.1(: PLA.('1:',s ,. kt.,Sga 101-1100-2554l(?(? S3.5029
s1lIR-1yTrA1.1("0NS-rR1,JrT1(YN 4NT) Pt('.AtNp((4114`9
U,1t11
(A�1
V�1.f ,
TOTAL PIERAVIT F 1: EY OVE NOW
14,7142.03
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
— &—" pct
Return Air
Steel
Combustion Air
Roof Deck
^a?
Exhaust Fans
O.K to Wrap
Framing
F.A.U.
Compressor
Insulation Z__
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Zo— Op
Atr
_
Final
Final
BLOCKWA
PROVALS
POO S SPAS
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
Sewer Connection
_ _ - /
��� l
Pool Cover
Encapsulation
Gas Piping
Gas Test77
/
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 S
Utility Notice (Perm)
COMMENTS: