0008-101 (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
6740 ;!`4 BCr7/3
I /'Z(
Date ' Signature of Contracto`rV •
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 jconst ruct 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:.
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 thi' ,permit is issued. :' 3
( ) 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'FTATI1.FU1 D Policy No. p46-0001:18
(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 Californid-Nd agree thatAf I should become
Subject to the' wofkers' compensation provisions of'Se&ion 3700 of the Labor
Code, I shall'fortfiwith comply with/those prov sions:`
Date: It "9 /G0 Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to.$100,006, 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
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 representativ p.of this City to enter upon
the above-mentioned propertl orriinnspect o purpose
Signature (Owner/Agent) ! F"I Date t r r5
� P
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ^101 TRACT
1. ► C-0 SM2A iSN1 468 29457.1
JOB SITE
ADDRESS 48,-770 WWW
APN
649400-M
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M DU- MCS DEVWPMMT
SPARX,8 C0NM`1'tUCM01a
t'OBOX 17 16
71215 ?JNCHO LsA QVWrA DX.
LA QUWA ah .92253
LA QUINA CA 92253
. (760)7' 1.1941 C13L# 2996
USE OF PERMIT
SWOLE F'A t: Y I?V1L1.<L 3144
3FD, 1 OT:6& PLAN:Mill. b PEMIT DOES NOT .I'NC1,U17L J81,0S:3tiRLLaDR.
POOL. 15% PUM CHECK Fly E REDtICTION FOR MULTIPLE ISSUANCE OF,
SAME PL IR TYPi
CUSTOM, CONSTRU0,TION 3,348.00 SF
P.ORCH/PA110 '580.6080
0ARAC)EXARPORT tS t�,ssz.ao
&-17i'aw) con Or OO1NS'rRYTanon
?112;lOC.t'U
PER.Mn, ' PEE SUMMARY
CONSTRUCT1614 FI W .- 101-000-438-000 $1,280.00
PLAN CHECK FFL 101-000-439-318
MECHANICAL FE:& 101.000.421.000 $143,50
E1:,P.0 'RICAL FEE 101-000-420-000
PLUMBING FEE 101.000.411-000 $202,25
9TR.ONQ Ib OTI014 FELE • R. IA 101-000-•24.1-000 *a2&.21
tYt,'t
ORADINCF 1.011 101.000�b2! P000 $20,06
DEVEL OPERIMPACT PEE 11,90700
ART YN PUBLIC PLACE:9 - RAIL 701.000.255y000 $205;227
ryoSULRV41O .END PLAN' CIEWY
• P�l�.sua-T4.
$LX00
.a ..' WMI, P?I'"1Ri1"S DVL NOW
RECEIPT
DATE J
BY p
DATE FINALED
INSPECTOR
Jv
INSPECTION RECORD /t
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
1 /
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
l _
F.A.U.
Framing
Compressor
Insulation
_
� �'
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath��
"Final
Final%�
BLOCKWA L APPROVALS
POOLS - SPAS
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 Z L
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
_
Pool Cover
Encapsulation
Final
COMMENTS:
Final
Utility Notice (Gas) f�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke DetectorsOf
Temp. Use of Power f
Final
Utility Notice (Perm)