0008-107 (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 ,�� y
6741077 B r�) 0--t'M17.1c
Date / Signature of Contractor ` 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
compe sn stion, 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:
( ) I have''and.will maintain a certificate of consent to self -insure for workers'
compensate �; 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 ST rF FUND Policy No. 046.000`7338
(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,.,l-should become
subject to the workers' compensation` provisions of Section 37000 of the Labor
Code, I shall forthwith comply with those provisions.
Date: �; / °`- Applicant
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 day's 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 represents ives of this City to enter upon
the above-mentioned propertty�f�i�pection purposes.
Signature (Owner/Agent)' Date '
BUILDING PERMIT PERMIT#
DATEI VALUATION LOT��'� TRACT
14 29457.1
JOB SITE A
ADDRESS 'a - VI.S��,rx,�.&1VY,1J.,iA
APN au�n
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M I9ESW INIVI FLOPML+M
SPAM C 014S'IRUC' 014
PID $BQX 1136
19.295 XAXCT10ZA.C11JW_. DR,
LA t1UWM . CA 92253
LA QUINTA C.A. 92253
(760)VI-1941 C!DL0 2996
USE OF PERMIT
=FPWILY DWEI..:-UNO
Sfflr' LOf:74 PLAX.MI - PERMIT DOS NOT INCLUDE BLOCKWAIAX OP.
POQL, 75% PLAN CHECK PEP, KIEDUCT1014 ICOR MUVIPIX ISSUANCE OF
DAME PLAN TYPE. r
CUSTOM CONSTRUCTION 3,3348.00 SF
PORCIi/RATIO 3'80.00 Sp
i' ARAOWCARPbRT (SP) I V82.80
't
coyr OF CORSI RUCnon
292,106.0
CONSTRUCTION FBI! 101.000415-000 J31e30100
PLAN CHECK IFEL 101-000-4-39,318 $264.23
IbIECHA1,11CAL .KF 101-000.421000 $149.50
ELECTWCAL FEE 101-000-420-000 $215.04
PLUMBINO "19 151.000.411.000 j $202,25
STRONQ MOTION PCE - RESID 101 -000-2,41-000 $78.21
(•F "'€ �
OPLADINO FEE 101-000-425-000 126.00
MOVELC PER IMPACT ",1, $1,907.00
I'`�
ART IN PVSLIC )PLACES - R&91r 701-(KIO-255-000. $20S;�i'
3 • �
S1J13-TOTAL O'C?�1: TRXICT10H .f NJ) PLAN IX
.$4,27 1- 5.0
LP410 PU.-PA tTa ilT;,
$0.00
O' NT, Mit?<4;HFnS lil0 VOW
RECEIPT
DATE
BY t
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
O. K. to Wrap
Framing
6
F.A.U.
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
�Ont
/
Final
Final
7a
POOLS - SPAS
BLOCKWALL A PROVALS
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
— Z3_Gy 6
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection
CEJ T
Encapsulation
Gas Piping
Gas Test
_ G
Appliances
Final
OMMENTS:
Final
Utility Notice (Gas)
V4l
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)
— ��