0008-113 (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
674074 f6 I T) 17 , ,1/3i
Date j" s r:'c° 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, as owner of the property; am exclusively contracting with licensed
contractors to construct' the project (Sec. 7044, Business & Professionals
Code). f
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty?, f� 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 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 $TATE FUND Policy No.. 046-OOV33
(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 p-aIs to become subject to the
-workers' compensation laws of California, and. agree that if I should become
subject to the workers' compensation provisions of Section 300 of the Labor
i
'Code, shall forthwith comply with those provisions.
Date: :� :prf;: Applicant—
Warning:
pplicant Warning: Failure to secure Workers�Coi"n`petion 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 inpection purposes. rr
Signature (Owner/Agent) Date`
BUILDING PERMIT PERMIT# ,
DATE ft j VALUATION LOT r 33 TRACT
I ` ou
t f ! $282,106AO q0' 294,37.1
JOB SITE
APN
ADDRESS 4.9-m.o wnA X51 YLLAs
64WI00-OM
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
� y1 �. r yq
'AJ.I.LJJL'd�•Cai�•J, DRIVE .OP.Win
SWARKS CON�'.Ti�l3M<5N
Ppb :E OX 1716
79.295:ilMCMIDT.AQ0:94XADR,
r
LAi illla'PA CA 92253
I.AQi7Y rA. CA. 92253
Q60)171.1941 MA 2996.
USE OF PERMIT q
OIX I(AW.L.Y" MM.; M40*
Slt`D- LO'17:30 PLA MI • PE MIT DOES'NOT INCLUDE t3LOCK''WA.LLS OR
POOL. VA PLAN CI ROX FEE REDUCTION FOR.MULTIPL�E ;ISSUANCE OF
SAM PLAN TYPE. '
. r
CUSTOM C040TRUCT1ON, /-,A34&00 SF
FORCKIPATIO' r 5$0.00 SY
0ARAOR/eARPORT (SF) 13,982.20
. ES'I11Yfl.MU) COW 011' A.rOMMUMM
282,106.00
np"T n Z gum"Ry
COAT aTAUCTION ME 101.-000-418-000 81,2-041.00
PLAN CI•iwic yEE 101,-000.439-318 $264,33
�>
MECHA141CAL FEE 101.000-421.000 $141.50
�
_ :;
ELECTRICAL PET 101.000-420.000
PLUMA)NO I'EE 101.000.41.0.000 UO2.25
� o >� �.
STRONO MOTION FEE • RESID 101r000 -241 -DW
CIi.A11INCt FEF 1.01 v000a4236000 $10.00
1.7AYIt.1 OPER IMPACT ME
ART IN PUBLIC PLAt~ ,' • RESIL 701 -000455-000 fm v,
STUB -MM CONM10C M10W AND :PLM CMICK
$.4,271.30
1;:V; 3 M -PAID PEW
$0,00
RECEIPT_ -
DATE,,
f, `�!
BY
DATE FINALED
INSPECTOR
-'
f
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel f
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
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
BLOCKWALL
_
PROVALS
POOLS - SPAS
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
1
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
Final
Utility Notice (Gas)j)
ELECTRICAL
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)
/
APPROVALS
COMMENTS: