9907-422 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that -I am licensed under provisions of
Chapter9 (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
697117 .1,
08 1/201
ate �� 1i r Signature of Contractor.1lrr
:OWNER -BUILDER DECLARATION t.
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&RC' 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'i§ issued.
( 1 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.
STATE FUND 4rS? �-(1f3vCt17fr
(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%fcompensation laws of California, and agree that if I should `'become
subject to the workers' compensation provisions of Section 3700 of the Labor
de, I>§hal�(orth Ij,�j�comply withitho e p ovlsloln�s
V6ate:.. !! I /Applicant' , .1 2, 12 /;Y I 1
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 asprovided•for,in Section 3706
of the Labor Code, interestand 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 applicator 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 pr6pe-4 f_o�r inspect'onpurposes. '
0ignature (Owner/Agent;), sV411 L Date.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (_99074 22 ►TRACT
��
.ry f{r t
I �� r�.X9Q� .,a'�,: j::a.' .. it
/ + ,.�•���%:�
JOB SITE �
APN
ADDRESS
604-071-611
11
OWNER_ _ T '
CONTRACTOR / DESIGNER / ENGINEER
+
[(i
�J0.0a'HAINlai,i D bY,ii.>.4i1'1.1Y4S-AS�.7�.��r;1V :
OL. 13"I.fA dAND iV'ILL1.1"IS i1..7SOIC•,.Id'C.,
'�-}gati :a iv! � 'UF'l 113 aTA S
77,5ItiC� A'EIJ'iJ`E OF "f RE STATES
PI'LLM DRSERT CA 92M I'
f'z'iLM Di'SE9.17 - - CA 'Y.,1211
i "rE 45-21666 CA31,# 45263
USE OF PERMIT
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. \�,� . 7. r.•. -tt� _ :.. a .A • ... 17� t�� _ n i� ;�. � tom, n .., ,y to . ,t ... f ,.
J[•id .•: i4..i.+•Y fr., i`.7,:.:�i3' c+'b t",c.R4tlI rjofwS NC)1 LNe_jnVDF,, xa(.:��Y� vN r1iia.0 ,
TRACTCONSTRUMION
P011C,"Wi AT -1® 58.00 4F
•
CAAA(I&Ct>R9?(1XT 496„00 SSE::
f
T4p
E"UNIx�'i`. ED COST OF CONSTRUCTION
0
104,757.80
P +`RTQi1'1' FEF SUAV.�'1. 1'
coN5.1"IZtIC;'t'YON r, im $A517A4)
'PLAN CHECK FE:l:HJ0 43 -31$
Edi H.t�a”' ICt -S. TIa ,, . ,. J01:000-421 -000 S4740
wi 000-42.0-00o
P A11013rNo Fit>
STRONQ'IN-10110 FEE a `SID ..WI -000-2 41 -OW
tyy,�'��DII{I GFE,tvEryff�
�+-pp?13-0}ij(lt�� @@!��t$2�((��,trt�
1.i'Wl,[.t STRI C UWi I♦.�E :Z h �'7/Ui1`•� 7^.;,IYL. - . .. S2,33d.Q-.
1?i.EC`18E, PLAN. '. S25.00
A 'I' :Lti pUi3C.1t: '3 i i'sS -'Itis flr,'1t1t fit3ii-SSS $11.89
Sit'B,,TOOTAL COI%IgCRLTCI'ION .�Y,i D PLAN CHECK
LE PRE�PATDF%
$0,00
OTA PEW E
�' 7
RECEIPT
DATEBYf
DATE FINA LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
g_ '7 6'�,G
Ducts
Slab Grade
%j'9 6'l�
Return Air
Steel
Combustion Air
Roof Deck
/� /���
Exhaust Fans
O.K. to Wrap
2-
F.A.U.
Framing
of W
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
Cd of
Final
Final
-Zs-
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
Waste Lines ��� 6'
Gas Test
Electric Final
Heater Final
Water Piping
j
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral�2
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
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 't,S
Utility Notice (Perm)
r