0008-133 (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
a,y
674074 B 071,3412C
f
Date • ` ¢ 4'' 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).
() 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 • STATH Irl D Policy No. 04640M.30
(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 the workers', compensation provisions bf Section 3700 of the Labor
Code, I shalfforthwith comply with those provisions\ �' { J, •�-�
Date: -il 0re- • Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject -to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection -purposes.
Signature (Owner/Agent) el i Date .rsr:�"?
BUILDING PERMIT ERMIT#
0OW133
DATE, ! ( VALUATION LOT TRACT
1.a i 1 %# t",2€30 100 2g:3? -1
JOB SITE• +
ADDRESS 49 s wS'2'A1:�"2''ft�lt
r.0
APN
649k�,�-M3 '
OWNER
CONTRACTOR / DESIGNER / EN INEER
11) D_ 1'"`I�'I'ZT i3VEWPIA "C
SPARKS COAT 31'R7i'C'Y. 'Ok1
PO BOX 1716
79.295 RANCHO LA Qi7MA? DID
LA Q)TTO IA CA 92253
I_k QUThi"rA CA 9225:3
oho) -n 1-1941 ('A'L # 2996
USE OF PERMIT
BWOLi, FAW. LY DWELLING
SFDf,. T:3a0 PI.AMMI - PZMIT I: OE$ NOT INCI.U)")Z SI OCIK-.WAIAZ OR.
POOL.. W% PLAN MC:Y IEEE AMUCTION.-FOR MC1�.TJPIX ISSUANCE OF .
SAME FiahM TYPE.
CUSTOM CONSTRUCTION 3I342,0A SF
PORC�11 ATIO 590.60 SP
CARAGE/C:!? RPOitT (Sn,
. . �/:. ►% J. ..1J 4'c0'ai 6' OF�:o.LY e�lIrRiU TIOii
20'J ,106.00
PEW. G Fn SUMMARY
C -01401`T UC110N FRE 101-000.418.000 $1.280ioo
K A.'1d CHECK FZF 101.000-439-318 a
MECHANICAL FEE 101.000-421.000 $140,50
ELECTRICAL !l t 101-000.420-000 $215.04
: f
PLUMBINO FEE 101.000419=006 $202.75
5 P.ONQ MOTION FVI,= RESIb 101-101W-241=000 $28.31
09RADINO FEE 1011.400.42<000-
mvp,LOPER IMPACT M
DIRT IN PUBLIC PLAC . RE61170.1.000.255.000 $205:
r .;� 1,T1
4` k. 4 •4..
=13 -TOTAL COMM'RUC`I 109 AND PLAN CI CY
1M3.ME-PAID xFMR?
MOO
OTL .T_4JM Irr En DUE NOW
.1
4,271
RECEIPT
DATE '
BY ��
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— f
Underground Ducts
Main Service
Forms & Footings
Ducts
Exterior Receptacles
Slab Grade
G.F.I.
Return Air
ol
Steel
Temp. Use of Power
Combustion Air
Roof Deck
OX to Wrap
_
_Al
xhaust Fans
F.A.U.
Framing
_ _�J _
Compressor
Insulation
Fireplace P.L.
_ _ _6l
p
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Q/
Final
- 02
Final— —�� — Z
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
�.�- /_
�/
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral�
Sewer Connection
/G�
�f/
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
,OMMENTS:
Final
Utility Notice (Gas)i/'
`
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
I Final 1 2a--�'
/�%�e�zs