0002-102 (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
07761M(
f, D.
Date Signature of Contr
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of,perjury that I am exempt from the Contractor's
License Law for the following reason: r
( ) 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:
Carver Policy No.
7 t tn� :, e .e
(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'se as to become subject to the
workers' compensation laws of Calierma, and aglree'that if i shout become
subject to the workers' compensation provisions of Section 3700 of t e Labor
Code, I shall , rthw'th comply with those provislo05
Date: Applicanty ^
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 requesi'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 authorizefre- �entatives of this City to enter upon
the above-mentioned property for'inspection purposes. r�
-�,-
Signature (Owner/Agent) i -�'"� Date f % I -'rr
-- PERMIT # +
2
/ �' BUILDING PERMIT
DATE VALUATION `bfl�)yi7a�,l.V LOT TRACT
JOB SITEiF^27w1 6 8.'s,i f}i C:���� �D
APN �q^lk3t�-[%74.
ADDRESS .
OWNER
CONTRACTOR / DESIGNER / ENGINEER `
p,+� 21y ')141111 T P'nr}::� I'
SPARKS Ct"WS"j'F�.,'C�7Jag
Po jK:I'r 1 u
7ts-293 RANCHO Uk. (,7UII TFA DR.
LA. QW v` A. CAT 922si
GA QUfN'lA CA 92253
{1)771-1.941. C L#` 2996
USE OF PERMIT .
'a1NV1..r1.,E T,;A1W1LV i.yWOELIN
/
S .0 -LO a _i 4�.ILAK :'L; 41C-1' f A JVlsS 14 r i� il4CL tfJE TtiLdJi is. -WALLS � S i lit
POUL,750A.tI)..AN C HE,C'h": AS-81.tE.DUOfI'ON OR XOJi. 2 tA°U. l[3:3 A.NCF OF
SAME ftJCN 1`%. TE,.
cz,ywra%a cmis'faafJG°i'toti Z635poo Sit
?iE�.FUk'fl'.t�il� u!b/Ulf
e3iiZelc3 ICA:?iE'fti' 614 (ail SF
E,101 11111isTED COST 01" R..Od'VTu AFRIUty. 17. ON
C0NS`TRVC;'rS.0N:F'E! 10I4)0t?- tN_0f1U
PLAN CFFCK FES t 0}.d*0-X239-;1 f 8
NIECIM11CAL 1761;
BLEt:`MCrAL F'EFS
1'i f AIWLNO F f �81 101-00-419-000 19-000 S179) '25
3:VUCI'PFUR Uig ACT FIX, $1,907,00
Aff TN'+Vt L'IC, PLACES .RF_S.a,' 701-000-255-000' M233
S tB:MT.J4?., trO.Rt`STR TCRiON AND 11.-AiNT Cf TICK
$4,61i.04 '.
TOA NI,, 11IMNUT F:CF;8 D )'E NOW'
RECEIPT
DATE
W, X
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS ,
Set Backs
Underground Ducts
Forms & Footings
Ducts j
Slab Grade
— —6'd
Return Air
Steel
Combustion Air j
Roof Deck
Exhaust Fans
O.K to Wrap
Framing
/ //LL
��
F.A.U.
/
Compressor ,
Insulation
//
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
i
Exterior Lath
j
r
Drywall - Int. Lath
_
Final If V7
Final
POOLS - PAS
LI
BLOCKWAAPPROVALS
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 d p v
—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connectio
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRI ,
L A PROVALS
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)