0008-109 (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 # 2�Lic. Class Exp... Date t j
Date " °%' Signature of Contract'r,._M
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 co'n'struct the project (Sec. 7044; Business & Professionals
Code). "-` e
( ) I am,exempt under. SectioM� B&P.C. 'for this reason
Date- _Signature of Owner
WORKER'S COMPENSATION DECLARATION
L' hereby affirm under penalty; of perjury one of the following declarations:
O 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 whichthis 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:
CarrierPolicy No.
�xA.r>� I�u1dly 046-oA0'3339
(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 Cal ifornia,,andsagree that if I,should become
subject to:the workers' compensation provisions of Section`3700 of the Labor
.Code, I shall�forthwith comply with those provisions:
Date; ;'-, ; y ,"� Applicant—
Warning:
pplicant Warning: Failure to secure' Worke s'*Co p nsation coverage is unlawful and
.shall subject an employer to criminal penalties and civil fines up to $100000, in
.:addition to the cost of compensation, damages as provided for'in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application. is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his ..
application.
1.'Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to .
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from. date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information.is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby autho{ize repres6intatives of this City to enter upon
the above-mentioned property f 3 -inspection purposes.
Date Ff
Signature (Owner/Agent) .-� f
...
BUILDING PERMIT PERMIT#
j
DATE - f�✓'. VALUATION LOT TRACT
r
I{Il"r 00 7f 299457* 1:
JOB SITE!
ADDRESS 401930VISTA 7f:l4'7IMLI,A
APN
,649 -100 -OW
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M DESEW DE111rLOPIV"E
SPI Pam 010Wrizu "r'dow
PO BOX 1716
79.295 RAN r-B0%,r> QW NTAx7R
A QUNITA. CA 92253
L.A QI UWTA CA 922-3 3
r
(76,D)771-1941 dB11ft 29.96
USE OF PERMIT
M14CLE FAW. Y INW,I.dl G
Sf+; - L01,16P1.AN:M1 • PERMIT LIOES NOT tNCLUDF, BLOCK WALLS OR
iPOOr., ms PLA1_+i cm ,& FUODucrio d.FOR MULTIPL.9 ISSUANCE OF
SAME Vt,.A�N TYPE•,.
CUSTOM t;O�TBtv7fQl+l 3,348,00 OF
PORCH/PATIO 590.00 SE'
i
OAR.ACIE/(,A1tPORT (9F) t.%532,80
- a0
r .
I
ES71hW .COST OF CO NS1°]'EIUC'1'tON
292,106.00
PRIORT nom; WhWARY
CONSTRUCTION FEE 101.000.415.000 51,2.30,00
P .A14 CHECE ME 101-000-439 31$ �2Sst.2
MEC3H-ANICALFURE 101.000.42.1_-000
9L TRICAL FER. .101-000.420-000
STRONO MOTION FEE • R:ESID 101.000-241-0001
CJfiADINO FEM 101.060-423.000 520,00
♦ R o `j +.
DI:VEI DP}rA IMPACT FFZ .
ART IN 7PUBLIC PLACES , RMIL 7011.000.255-060 UW121'
SUB -TOTAL CODT..I "t M034 A.WD PLM CIMMC
$4,271.50
=4 PRE -PAW F
S0100
TOTAL F) AU`(a.' FS 1?U11":1 (YW'
$4,271,50
RECEIPT
DATE jJ
BY ";Xi,
DATE FINAL ED
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
_
p
Exhaust Fans
O.K. to Wrap
%
F.A.U.
Framing
Insulation
Fireplace P.L.
Z
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
_
, r
Final
Final
POOLS - SPAS
BLOCKWALL
PPROVALS
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
Appliances
Final
OMMENTS:
Final
Utility Notice (Gas) —60
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) -