0008-141 (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
13
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct _the . project (Sec. 7044, Business & Professionals
Code). J
(') I am exempt'under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
1 .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, fo-r the
performance. of the work for which this permit is issued.
( ) -1 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:
Cartier S'IA.TL Policy No: 0460007338
(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,,and agree that"If\l should become
subject to the workers' compensation provisions of Section 31700 of the Labor
Code, I shallfforthwith comply with/those provisions. ✓
Date: �r' - Applicant ' kY f --'
,;..�'
Warning: Failure to secure Workers' Compensation coverage is unlawfu anid
shall subject an employer to criminal penalties and civil fines up to $100,000,,in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is. hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each.person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued'as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I haveread this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby? au h`orize repress tatives of this City to enter upon
the above-mentioned property for inspectionipurposes.... tf
Signature (Owner/Agent) `�-°` 401 .. Date
BUILDING PERMIT PERMIT#
DATE t VALUATION LOT TRACT
TRACT
79457.4
JOB SITE'
APN
ADDRESS 8-075 VV`l."A ES iii >L,LA
6494W. 0019
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M DF.Mer DEVEL.C;+PMFIK
SF:ARFi:$ CONSTii UC'11014
PO DOX 1716
79-295 RAHCHC3 �A QUINA DR.
LA QT3-.tk1" A CA 91253
LA. QU,C1d'I'A CA 92253
(7650)771-.1941 C.%Vt M6
USE OF PERMIT
�a�a�.rA��.,� D•i��c�
.
5k'b,J,0T108 PI ATI:MIR PERMIT IJO fru 140T MCLUVIt, EL:OCKWAI LS
OR P006 "Aft PLAN CfIEI"..K F,E REDUC T 10111 FOR M1I,L,TIPLE WS,UANCE
OF SAME PAF TYT'&
CUSTOM CONSTRUCTION 13413.00 OF
PORCH/PATIO 380.00 SF
GARLAC1WARPOR.T'."S 13s382,0i1
E6rD. VX C:f,3S° OF C0N8LR17=0N
282,106.OD
CONSTRUCTION iTRUCTION ME -'101-000-418-000 $1,280.00
PLAN C°Y3=K ME 1t33w{1004439-31� �2Gri.23
� � �x, :''.
MECHANICAL FER 101.000-421•=000 5144,$6
EL�t TRJCAL FVZ 101-000-420-000 $215.04
PLUMBING FEE 101.000.419-000 $202,2
377 ONG MOTION FEE �.ZaS1D 1.01.000-21'1-000 52121
ORAD1pJCl"I`'F.E 101-600-42i2-000
DWELOPER IMPACT FEE $1;407.00
Thr -•=I
ART IN PURI IC PLAC.Er -1YE70I.000.255.0000
Ct-'it]`IAC. C:ONO'1ttLTC�I'QY3 A1iTi?n1<l Ck31C%
$4,271,50
L13130 F ,.PAI
V�11,SSNOW
r$0,00
RECEIPT
DATE, j
i ,�
BYE. j
�,Yi �
DATE
INSPECTOR
j t +
�
^
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 6_.
Return Air
Steel
Combustion Air
Roof Deck /
O.K. to Wrap 47
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation 3a/�
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 dr
Appliances
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)