0008-104 (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
�f
X74,:074r r� (y7rA 1/2t
s"f !�lf 3.. f .
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). e
( ) 'I, as ,owner of the property; am exclusively contracting with censed
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; 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 04fs OOD7338
(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
subject -to the workers' compensation provisions ,of Section 3700 -of the Labor
Code, i shall forthwith comply witK those provisions.
Date:l� 'err °r' Applicant f
7
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and.civil firfes up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for .a permit. subject to the conditions and restrictions set forth on his
application.. `
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.,
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance .of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for in�spectiom purp s1s t
�..�;
Signature (Owner/Agent)` -Date 7 f �"" In
BUILDING PERMIT PERMIT"
DATE ( VALUATION gauyy�q yg♦♦����- !�7f,n� LOT TRACT
29457-1 yy
JOB SITE i I
ADDRESS, Qg-�� V►63iE�.�ale�.
APN
649-100-•W9
OWNER
CONTRACTOR/DESIGNER/EN (NEER.
ID iDOERT 17E." .01' 'i f
SPA1ZXS COXa lk-,11Ola
PO:t$ox 17)6
79.29510SCHO LA Q", T DFL
LA, QtTINTA CSS. 92253
LA O't? zWfA CA 9..2253
t It
(760)711"1941 L''�:0 2996
USE OF PERMIT
SMGt:, , YA1 DLY D'4J LUNG
SYD- I OT.71 FL,.A3J 3111 - PERMIT DOES' NOT iWGLUVJF B.LC7CiCWALLS OR
POOL, 7S''rb' k LAN ChIItC:i;; F&B REDUC T ION FOR MULTIPLE FSUlt NCE OF
SAW PIAN T tfi E. '
CUSTOM CONSTRUCTION � %348,00 OF
POR,CH/P.ATI& 590,00 SF`
dkRACiVCAAPOPT (9F) 1.082.30
•
a ..r
xt.
.% ES'1nM1XD. COST OF COXVMU fJOlY .:
all,
9.82,10&0Q M,
C01+ OTRUCTION f1w . 1.01.000.418-000 $1;2go 90 ''
° ,4
PLAN CHECK F99 101-0.0(1439-318 $264.23
MW,HAN1PAL PEP, 101.000-421-000, 014100
K1,80111CAL IMSr 101-000420-000
P,1'.IUMBINC3 FEV.. 101 *000-419-000 $202.25
STRONG MOTION FEE - RMID 101-000-2:91-000. $28:31
O 3.P►i IWO FRF 101-000-423.000
nA."t��LL7Fls~13 IB/JPACT' 1 $1,90'/:00
ART 114 PUBLIC PWW90 .C1.E.9IC 701.000.255.000 5205.27
1A,.
S.YB=TOTAL CONM,- X 001109 AM PLM CHECK
$4,271.50
LUS PRE -PAID.
MOO
'111AA Ll 1'MMIrr 1g DVE 1-4ONY
$4,271-50
RECEIPT
DATE
fq ".
BY
DATE FINALED
INSPECTOR
I !
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
/v -v/
Exhaust Fans
O.K. to Wrap
0
F.A.U.
Framing
Pf9
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
_
a l
Final
Final
POOLS -SPAS
BLOCKWALL AP ROVALS
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
— Z
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
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
/
ELECTRICAL A PROVALS
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)