0008-111 (SFD)LICENSED CONTRACTOR DECLARATION
1 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
t;7�4t)74 ID
Date a r°' Signature of Contrac 1nr
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 tt6 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 aad 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:
Carver .STAPH FMID Policy No. 046-007333
(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" fel should become
subject to th"workers' compen sationl0fovisions of.Section /3700 of the Labor
Code, I shall forthwith comply with those provisions
Date: f; r + �` *� Applicant _/ !-' / I ►
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 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 authorize representatives of this City to enter upon
the above-mentioned property fo`'irtspection purpos.
Signature (Owner/Agent).
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0008-•1'1.1 TRACT
A _ �; a W5 ,W 78 294 7-1
JOB SITE ;
ADDRESS 48-970 WMA.):S-'iWv.KT.JA
APN
649-1(1QI 09.9
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
PO BOX 1716
79-295 Z2AH6140 L& QUINTA DSR.
1A Qi INTA CA 92253
LA QU.fAd'I'A CA 9225:
(766 771.1941 CTiM 2996
USE OF PERMIT
MOIX,1F'AM_TLY DV,% 'O
SE5- LOT:7H PI.AN:1 2, PIEI MIT DOE.`; NOT INCLUDE 5.1,OCKWAL.LS OR '
POOL. 7550 PI,A14 CH.WX F11 ,RIEDUC 1 ION.FOR IU ULTIP149 ISSUANCE OF
SAME PLAN TYPE
CUSTOM CO2I8T1Zd&, ION 3,556:00 SF '
FORCI-11PATIO 446.00 SP
(O.ARAC E./CARPORT (OV) 22,465.60
71"ED COSH' OF CON s fRUC" i'.I0M
Xy,
2951409.EIt1
�S
p•�ysyay�yi,,��vqy yy;; �YrL� [[vv ���q�
S x.AK.1:iMI:Fr.L`.N.a: e7Ui�."F.+:vcr,aMv.x
OOMT RUCTION FEE 101-000-418-000 $1,324.50
PLAN CHECK K�$E 101-030-43941
'MKCHAAiaL RE 101-000.421-0041 4124.00
MECTIZICA). FEE 101.000-420-000 $221.18
-
PLUMBMGF3E 101.000.419.000 $220,00
_4 ; ..
STR'.ONO MOT)d FEE - RES113 101-000-241-000 $29,34
c' RADINO WE 1:01-000-42$.,000 $20.00
bEVELOPER IMPACT FE �1,rJp7.t1U
� �1 •'.'L
A1t'I Ili T'iJIBi C; ALACU�S - RVIqJE 701-000.255.000 $233.5
e,,
:i
LESS IRE -PAID F€EO
$0.00
'T'OTAL T'1110 i' 11015 ME NOW
$067.556
556
RECEIPT
DATE / f
BY
DATE FINALED
INSPECTOR
lZ
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs ��//ff
Underground Ducts
Forms & Footings G��i'\
Ducts
Slab Grade .y��% ��
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap _ _ _d� _
F.A.U.
Framing
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
_
Final / -
Final
POOLS -SPAS
BLOCKWAL A PROVALS
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 '7— 7_A47
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral t
6� �
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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)