0008-140 (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 /
B /EY71.31 st.(
;� I �i rf✓,S
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
( ) I; as owner of the prd'perty, am exclusively• contracting with licensed
contractors to ,construct th'e project (Sec. 70.44, 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'
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 . S
TA
TR FU14D Policy No. ' I146<00fYM
(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 theworkers' compensationprovislons of Section 3700 o the Labor
Code, I shall rforthwith comply witht ose provisions.. r
Date: r• +r °?A ri Applicant f 1
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,0001n
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 forthon his
application.
r
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.df 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 V 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 prop- y for inspection p poses.
Signature (Owner/Agent)--•-- "^y«' � Date F✓ 1 r 4, `f 1
BUILDING PERMIT PERMIT J/
DATE (i VALUATION LOT \ 0�Q
5.1 3N.;1.� � TRACT
9457`1
V 29457-1
o t
JOB SITE ! y
ADDRESS. 4& i, � ai,l, ✓! ad. `�
APN Q
Y9 MM3-
6Yp
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M DIMRT DL'V0,0PX1vff
ISPARM CONSMUMION
PO BWA 1'716
'19-295 RANCHO LA QLT,I3 . A DRI.
LACZ`Mx, ('A 92259
LACZL�-MA CA 92ZS3
('760)771.1941 M0 2996
,
USE OF PERMIT
8WORLt FAM LY DWELLING
SPD. LOT:107 PLAN:M3 - P RMI T DOES NOT INCLUDF, HLOCKWALLS OR `
POOL -6% PLAN CHAC Rik REDUCT ION FOP, MUL IP.tX IOW. ANCT OF
SAME PLA)4 TYPE,
CUSTOM CONiTRAJdTION 4;243.OQ OF
PORCHIPA i IO ' 527.00 Sfr
0AR:AOEIC.ARPORT (SV) 13,4tb,ba
9SiMATum C09'r Ole GOln7MiiMON
►
PERMT &U1VTA"RY
t., ,Z f
C'6143TRUCTION FLM 101-000.418,000
PLA14 CHECK r"L E 101.0 0-439-$1l$ $3(i�. is
•�° � , ( ,
MECHA141CAL FEE 101.000.4.21.-000 S f 36, g0
ELECTRICAL3 f; 101 -000-420»®
PLUM80110 FEE 101,000.419=000
STit.t"N0 PA0TION FEE MM. 101-000-24 1-.00.0
CRAX)INCI FELE 101-000.423.000
r..?i;VBLOPM IMPACT FFF, $!,90'7.00
#+.a
ART IN PUBLIC PLACES - REME 1101-000455.000 S.379149
81H,-Ttib'A1. C NS`l:R'C)C°1'ZGk4 .IAND PLAN C EFf-4K.
$4,759.03
IMP PRFyJ?A.D M4J
$0,00
TOTALIPEPMT1 E SSDVE HOW
$4;759,05
RECEIPT
DATE I j
By
DATE FINALED
INSPECTOR
!
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
t�
` '
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_ _
_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
r
3�f1—
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
!3
_
Final
Final
_
e�
POOL - $ AS
BLOCK
ALL APPROVALS
Steel.
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover I
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/B,
'�/
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
l
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
100,
Fixtures
Main Service
'
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
l
Final
_Z��
Utility Notice (Perm)