9907-423 (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
+Date / Signature of Contractor �` " ° ` I
' 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
(: } 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 tfie 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.
J_
I have and will maintain workers' compensation insurance, as'required by
on 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.
Sl.ATE s?f?Oi3t.
(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
Esu t�t�tq' the/ w Akers' compensatlog/pro•,vlsiops °�f ectwn. 3700 of the Labor
de, I Ah617. �hrVh comply with those��ro� slonS
VDate: l! ! .:.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 3.706
of the Labor Code, interest and atto'rney'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 Js 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
oorrect. I agree to comply,with all City, and State laws relating to the building
construction, and hereby, utt�horize rep, sentatives of this City to enter upon
the above-mentioned prope' f,eP'or 'nspe ti n':purposes'. ' t
I't1 1.ignature (Owner/Agent) Date
BUILDING PERMIT PERMIT"
1 2-3
.DATE VALUATION LOT -�'�i • 1, RACT
x S.134,373.00 :�yaS3
JOB SITE
APN y
ADDRESS r, s_,,,��y-'v-•�--y,_ ^��p*�--a, a-y�!' •y�
}�'f A"�.�➢:.�,.1-'lAeLr t[•. �.9r7 E l� Y @��3.� 90Y�i!,' �I
,,y�,f y;!5 „�,Ea
YlL`�I'L7I �`i➢.9 .Y
OWNER
CONTRACTOR/DESIGNER/ENGINEER
OL IPS-€.aI'T;AIND :'ss~'iMI,t NI ASSOC,'..- W.
OI..I.P.t•3.ANTP:AiD tJLrlw.LUMS )kSSO;, WC.,
f 7_400 A I EtNUR OF T HE S SATES
V-906 A%TivUE STAB T1 ES
PALM DESERT CA 9221E
P A.LM DESERT t CA. 9T2I I .
(7,60)3$5.2626 031,# 520'
USE OF PERMIT
S,,FI) - LOT 88, PI.At�t 2RC;, :PBMT PDOWS' I+ OT Tf CLUl7!, UL.C+CK "MALT,
OR POCit,, 75% PLOT.CHEC;S FEE FOP, 1iAtTt 'W1,F 1.3%,TA. XCH OI` SAMP
t>I i t irPE
ILA `'•�:I"1'
TRACT CONSTRUCrICYN 2,204.00 ISF
t>C)I�.Gr aATtCi 7,550.,30 SF
f r
0A,RA,GEIC:ARPOR'T 6480) SF
•
;fes ,..,e•!
�� �a�� c:a �A c �� ,ON T T�: 101IN
1. ,373.00
PERMIT IIFL SUMMARY
CIONSTRUCT101ISFMI
PLAN C_ ECKFEE
:ar air FFA
!Ef h 000-47 NOC PIYCALClit$W.60
P111?NMING 'F F J.O.I-4?t14? X319 OflO $SID , 7
S'I'RCjNG NIC) x ION FU -1 - RES.I1.7 101-4 00.24. -4 %) $13.44
CiI2Af)I21(^a l lEF 101-000.423-000. 3ix0.00
WRASTRUCTURF FEE. M.3.000-44; -342 55'9"4,51
PRECISE PLAN ICi,8-�I00,4d1 ; ��g.clQ
AR`T IN P_UBL.1C P LAr_FS. - USID 7UI-000-255-I3"N Ws 93
SU�3- C�I:�+LC'ON [k?'LIG'�`�ON-ANDftw CHECK
S:%.,fi53,24
LESS PRE-PAIDFETS
$0,00
Wri-O'EL ,Iali;RMIT"liUNS DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
7, ��
` -
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
(� i2 X60 ��
Compressor
Insulation
-66 WIF
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
J- Z g- o® 0
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines //�
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral/
Z /� n �_
Pool Cover
Encapsulation
Sewer Connection 6
Gas Piping
Gas Test y_ I
t
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fatures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final a 3
Utility Notice (Perm) ra