0008-103 (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 # .y Lic. Class Exp. Date
7/1
Date �' X �J'���Signature of Gontr"actor ✓ r_ % ✓
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 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.
( )' I have and will maintain workers' compensation insurance, as required'15,
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. 046-09M.,38
(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�m, nner so as to become subject to the
workers' compensation laws of California; and agree that if.l�sho Id become
subject to th'e workers' compensation provisions of Section 3700 of the Labor
Code,shallt.forthwith comply with those proLisions.^
_Date: ;�1� li Applicant'f ( �'� (N „r•
.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,S'fa.W laws relating to'the.-building
o iie repr sentatives..of t is City to enter upon
construction, and hereby/uth
the above-mentioned property for inspection purposes
2.7
Signature (Owner/Agent,' ' ' Date
BUILDING PERMIT PERMIT Ii
DATE VALUATION LOT 0O 1'03 . TRACT
70 r. Z9457-1 .
JOB SITE i
APN '`�' '
ADDRESS 8.810VT"AF.S13ZFJ.L-A
64941,
OWNER -
CONTRACTOR / DESIGNER / EN (NEER
M D1•;SPAT 1)FIVM C>I:'IvE9T
VARK.S C0HMRI:J=014
PO BOX 1716
79.2-93 :P.AN LA Q13iATl:A DR,
LA ( e1:iJ=A CA 92253
LA QUINTA CA 9?.253
t U)�t71 1 4l CM4 2996
USE OF PERMIT
MOLE3 FAM LY DWMJJ140
SSD- LOT - 76 "PLAM:N1312 • PER MIT ]DOES NOT MC LUt?aE BLOCKINALLS t)it.
POgil. 75% MAX CHECK Ml? REDUOTION FOR. MULTIPLE 19,10 WCz OF
S,A,ME PIAN TYPK
OSTO M C0118TRU&IOlii ,4, avio SIi'
Ptv:CI`IIPxrlt5 323.03 SF'.
GAIIA1139/CARPOR',I`,(SY) 13.9I6.4p
.D Cosi or congi',�'ucnoN .
Ity
CONSTRUCTION Iii,': 101.000.418.000 $1,521, 0
b
PLAN CHECK WE 101-000-439-31$ X305.73
�
MECFIANICAL FEE 101.000.421.000 t1300
� h
&, 1 j
ELECTRICAL FEE. 101-00"20400 $246.71
'
't r � #
PLUMPING ME 101.00 -419.000 $205.00
STROND MOTIMI ER - RES1D 101-000.241-000 $35.14
ORADIWO PEE 101-000.4.23.000
0EVELOPPR IMPACT IEI; �I,90'J.t10
AV W PUBLIC PLACE,,- RE.'jIE701-000-255.000 3s'.s;42
SUB -TOTAL C" 0141''51,'RX) MTOAI' AM PLM CM -CK,,
L1-33 T':F�IV-PPM 1�:5
$0.00
ssy �g++,�Y r v
RECEIPTDATE
R
BY
DATE FINALED
INSPECTOR
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
/
Exhaust Fans
0. K. to Wrap
Framing
_
p
/
F.A.U.
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
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
Gas Test
Electric Final
Waste Lines
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
� 73/�/
Appliances
Final
COMMENTS:
FinalUtility
•
Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
�—
Utility Notice (Perm)