0008-147 (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 EO Elate6 y
4074
Date 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).
( ) 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 ofperjuryone 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:
Cartier STA f F1r3i1aU Policy No. 04f3 b00i338
(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 Calif ornia,46 agree that .if I should become
subject to the workers' compensation provisions of Section 3700 of he Labor
Code, Ifshall �hwith comply with those provisions;. r;, tom•
Date: .I : . ;� 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. i
Signature (Owner/Agent] Date
BUILDING PERMIT PERMIT#
DATE ! VALUATION - LOT -11g7 TRACT '
114 29457.1
-
JOB SITE• J
APN
ADDRESS -4m �_ia A Fti+•� LA
649-100-W9
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1'0 BOX 1716 ..
79.295 RlINC1110 1A QiT3Ai'.1'A 13R
LA QU11+TfA CA 92253
TA QLTRTTA CA 92233
C/60)771-1941 CBL# 2,996
USE OF PERMIT
3]23TGLt FAWL Y DWM LWG
SI+D- L OTA14 PL.ANA43R. • PERMIT DOPE NOT INCLUDE 13LOCK:WALIS
OR POOL 75% PLAN CHECK. FEE R&DUCTION FOR MULTIP169 IS, UANC.P "
OF SAME PLAN TYPE,
CUSTOM CONSTRUCTION 4.243.01 Sly
POR.CHIPATIO % 322.00 SF
GARAGWCARPOWf (SP) .13.016.00
1 ffffK07D COST OF CC 14MUCTCOI4'
35113M.30.
P.R MT %ice a VN94"y
CONSTRUCTION FEE 101-000-418»000 $1,521,50
PLAN CHECK FEL 101=0004.39-3113 $M.7,->
� r
MECHA141CAL RE 101.000.421..000. $136.30
ELLCTR)C:A1, FEE 101-000-420-000 $24&71
PLUMBfN0 FFE 101.000-419-000 $203.00
STRONG MOTION PER • RESID 101-000-241-000 $35.1
C�t�Ai9INC31'I�. 101.000=4234000 820,00
f , j T s
DEVELOPER IMPACT FEE
.,,
ART .III PUBLIC PLACE - REAME 7010000-255.-0000 $3;��47
, +
STJJB IO`rr'.AL C0A1..T' RUCVrJ N AND PLAN CHECK
$4,759.05
1,E33 PRE-PA1D FMS
$0.00.
`X01'AL 1<'°,1s.` _Tr FEES D (TE OW
$4,759.05
RECEIPT -
DATE i
BY- t
DATE FINALED
INSPECTOR,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/ G
Ducts
Slab Grade
Z Zw ps)
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
r.-� �t
F.A.U.
Framing
_ ZX
Compressor
Insulation•0�
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
FinalFinal
rNp1p_)ROVALS
POOLS -SPAS
BLOCKWA
Steei
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
�y'J
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
(p
Appliances
Final
COMMENTS:
Final
`O. rte-sG �` �•�l e1
Utility Notice (Gas)
ELECTRICAL 41PPROVALS
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)