0008-108 (SFD)LICENSED CONTRACTOR DECLARATION
f 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
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
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 '
t hereby affirm' under penalty of perjury one of the following declarations:
I have an8 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:
C'arrier' STATE MD Policy No. 046.OP x9333
(This section need not beCompleted 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 agee that if I should -become
subject to the workers' compensation provisions of Section 3700 o the Labor
Code, I shall forthwith comply with those provisions. �'" /,✓
Date:.� Applicant ' �?
Warning: Failure to secure W6rkers:,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 authprize representatives of this City.to enter upon
the above-mentioned property for inspectioApurposes:
Signature (Owner/Agent)` Date r�►. !
BUILDING PERMIT PERMIT#
3
DATE f VALUATION LOT. TRACT
1 t rj l o o 15 z �5:ia1
JOB SITE i
ADDRESS 48-91.0 VISTA X,tiiTR',FJJ A
APN -
454S�•.I0()_W
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TD DF,MT D1rVEL0PWW. T
SPARY; CC NUTRiTcrW
PUB Y41716
.7 9-2,95 :E2MO-101A QLYM fA DFL
LA Qtlf RTA CA- 92253
%A QU1b A CA. 92253
(760)771.1941 CE1A 29%
USE OF PERMIT
9ti1tCRY FAI& .Y I'WffJ.JX0
r
'PERMIT DOM NOT INCi UDR T3I..C;C;Ci�fALtJS a'"7Fi'.
POOL, `i 14 PLAN CHECK FEEREDUCTION FOR M1111 IPIA 1MU CE OF '
SAME P11AN TYPK
CUSTOM CONVAUCTION 4,243.00 SF
PORC H/F.AT10 j S 1.0U SF
OARAOFJMPORT (SF) 13,916<40
Co) T of cON&`T.C217E" C3x
.
�yy��. /p6:�Y,s pES�'XIMAT�A
qgy�-�yy YES
PiW.S.CV.II�.I .[rES tAli.lY:ltYiAR 0
CON6TROC1.1011 FE 101-000.418.0$10 $1,521.30
PLAN *19CK SEE 102-000-439-318
I E01H.ARICALl91S $136,34
EL C'rRWAt.140E 101-000-420-.000 $2416.71
�-� "?"1
T�1.1ila1tsl CA F94 101.000>419.000 S203.00
STRONOMOTION1 VER It,3',�ID 101-000-241-000 $35.14
CI12ADINO FER 101=0pf>°423•i1ii0 $20.00
I1EVELOPLPP'.IMPACT'FER
ART IN PUBLIC PLACES - RWE 701.000"255.000 $3±3.47.
SROB-107AL C0N•S'1'W0UI10kT MD PLM CirWC K
$4,719.05
0 PRF.-PAII) r -IM
$0,00
RECEIPT 1
DATE!
BY x
DATE FINALED
INSPECTOR
It ftr� tt"
f •'�£
INSPECTION RECORD
OPERATION
DATE
.INSPECTOR
OPERATION
I.DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
��
Ducts
Forms & Footings
Ducts
Slab Grade
—/
Return Air
Steel
Combustion Air
Roof Deck
_ _
y2 D
Exhaust Fans
OX to Wrap
/ /
F.A.U.
Framing
_ _�
7
Compressor
Insulation
/ pJ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
tOy
Final
/
Final
POOLS - SPAS
BLOCKWALA 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
J,
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
` ,
%�C�%
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
C MMENTS:
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)