0008-145 (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. pate
Date Signature of Cokntractor
OWNER -BUILDER DECLARATION
a
1 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, 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 STATE FUND Policy No. ��-sAR9338-
(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,ra i agree that, if I -should become
subject to the workers' compensation provisions of Section,3700 Of the Labor
Code, 1 shall forthwith comply with those provisions. firs. �lJ
Date: ,'r r 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
fora 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 3 { /
74
Signature'-(Owner/Agent)'" -i :^ sT }- :Date l L
BUILDING PERMIT PERMIT#
DATE / VALUATION' LOT3� g TRACT
112 2$43? • 1
JOB SITE'
APN
ADDRESS
48-695 AXVRnLA
645k -I00 -0i
OWNER
CONTRACTOR DE (NEER
TD .DF.9]F, T OEVELOPMWr
.41PARU CONSTR1iCi1ON
FO WX 171.4
79.2.95 _RM5..V101.aA Q:W3'ADX
LA QUTAP A CA 92233
l .A Q1JB1',CA CA 92253
.
�IaCJ}7'?l •15�41 Cl�itf� .2.99€5
USE OF PERMIT`
SFDa LOT:! 12 PL,AN:BAM • PERMIT I7UFS NOT rNCI.UV& BLOC iC'Ff AL.1 c+
OR PO+O1. 75% PLAN C14M, 'X FER REDUCTION FOR MULTIP1491SSU'ANCE.
OF571. Ar PLA23 i yClm /
CWTOM CONSTRVICTION 4 a4100 STS
PORCHIPATIO 521,00 SF?
0AR.AGrUC,•ARPORT (SF)
'ESTJMAI!?'D .CUSS' 0,' C0RS'TRW 110,11 .
351,".30
PERAW FEE SUMMARY
CONSTRUCTION U14 101,000-418-000 51'521.:50
'PLAN CHECK FEE I61.000,139-32$ $3omn-
�
MI+CHANICA1.FEE 101.000-421a000 $136,50
t z
8LECTR.IC:.AL FU 101 -000 -420 -WO
w.,
PLUMBINC1 We 101.000-419-OOO $205.00
STRONQ MOTION FEE •. RMI13 101.-0.00-2,41-000 $35.14
liflDI>40Fl1r 1011-00p-425-000 sao,vn
r '
OFIVZLOPER ]IMPACT W1
ART rN PUBLIC PLACE - P.F.01-T 701.000-255d000 5378.47
SUB-T(YfAT,, C01WRUCTSON AND P1_.AN C13ECY'
�d 959.05
1XIS-3 PREP .' '--
$0.00
RECEIPT.
DATE{ F
BYE
DATE FINALED
INSPECTOR -
r.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Z.—/z
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
b1W
_
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 c --r
_
Final
BLOCKWALL APPROVALS
_ _
POOLS - PAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
— —d a
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping i
Gas Test
Appliances
Encapsulation
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
_
Utility Notice (Perm)