0008-106 (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
I"
.
Date,/" �r`t Signature of Cont actor
9 ,.
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 .
( ) 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). P '
( ) 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:
CarrierSI`ATF, ii tJND Policy No. 046-0001333
(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 a d`agree that if I should become
subject to the workers' compensation provisions of Section 3''7,,00 of the Labor
Code, I shall.forthwith comply with those provisions. �
Date:'� r%� { " Applicant if
t f
Warning: Failure to secure Workers' -Compensation coverage is -unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. ;
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby au ' oriza representatives of this City to enter upon
the above-mentioned property for in's�pectiogpurpo se(, %
Signature (Owner/Agent) 1_ ✓ �✓,Date' I 5''f�
BUILDING PERMIT PERMIT#
DATE VALUATION - LOT 000%406 TRACT
1;0 3�29'a,40 .${i 73 29457-1 .
JOB SITE '
ADDRESS 4"70 WSTA F:STftT.? LLA
APN
649-4t30 om
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PO BOX 1716
79.295 RA1 CI.10 LA QUWA1PA
LA QTJ't fA CA 592:233
LA QTJINTA CA 9.7253
(360)771.1941 o ?916
USE OF PERMIT �
3FD- LOT. -73 PI AN;M2R • PERMIT DORS NOT INCLUDE 13LOCK.-WAUX OR
PO IA 7)% PUN CHECK FEE REDUC`1'ION RA MULTIPLE 19SUANCE OF
SAME PLA14 TYPE
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CUOTOM CONEURUCTION X536,00 SF
PORCHIPATIO 446.00 SF
OAR.ASIE(CARPOR.T (Si) 17;465.60
..s
. 'UTM COST OF C}T91CalloN
29,409.80
iLiY1' Y111119014NURY '
C0N3TkUC710A1 FEE 101-000.418.000 51,325,50
PLAN CHECK FLEE 101-000-439-318 $370:82
MECWtNICA), FU 101-OW421-000 $124.00
ELECTRICAL, 1W 101-000-420-000 '$221.16
'� a
P1,1.fMBIN(i TT,,E 101-000-419.000
STRONG MOTION FEIN - MID 101-000-241-000 $79.54
�•"" �"
GR A1a1" O FEF '101.000423.000 $20.00
r
DEVELaPER IMPACT FES
i r•' w
.ART W POLIC PLAC.tr`3 - RESIE 701.000-255.000
SUB -TOTAL >;:C31 SI.Rii"t;.`TIC>N AND PLAN COCK
$,367.16
LEW PES:-PAED Em
$0,00
RECEIPT
DATE '}
BY v
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
Underground Ducts
Ducts
Slab Grade
-�
Return Air
Steel
Combustion Air
Roof Deck_
6_
r
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Fireplace P.L.
_
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
< r�
Final
POOLS - SPAS
BLOCKWAL
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
_/ �_ _
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Ci C`OC/ _
Pool Cover
Encapsulation
Gas Piping
Gas Test
h
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL/ A ROVALS
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 Ilk
Utility Notice (Perm) j/