0008-116 (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
Date < <+ fJ Signature of Contractor t t
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 myemployees 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
r .
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 STATE FU141D Policy No. 06_00m3a ..
(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 of Section 3700 .of the Labor
Code,, I shall forthwith comply with those,provisions.
Date: i. ` 4 I-elo"t 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 author e: represe?tatives of this City to enter upon
the above-mentioned property for in�'pectiori purposes f
Signature (Owner/Agent)! i t Date' ` _
BUILDING PERMIT PERMIT#
OM -11.6
( VALUATION LOT TRACT
L� 388_83 : 9457
JOB SITE `
ADDRESS 4P_Q7E1 S F1 Se .A
APN
619^�-W
OWNER
CONTRACTOR / DESIGNER / ENGINEER'
TD DEM'f D1;” M,01'1adt`I'I:
SPAM C"OW`,1'Ir UCMON
PO BOX 1716
79.795 RMMOLAQUIMADR,
LA Qtl]NTA GA. 92253
1A Q11I1bN1 A
CA 92253
(760)771 -19-11
CBLtt 3996
USE OF PERMIT
2 NOLIE? 1"+'.A1•hi: Y DW+T.:i.,,]1 +
SFS• LC T:93 PLAN:M3 r PERMIT DOES NOT INCLUDE Bl;t�CKAVALL:,S OA
P001h 75% P.LAN CHECK _099P, REDUCTION FOR 1,R ISSUANCE OP
sAMP, PI. AN 'rype.
CUSxOM CONSTRUCTION 4,243,00 SY
PORCI•ilPBTIO
13AI2N,t' WCARPORT (30 I�,flIk.00 '
Z il`t}y w COST OF C01%S FR>a cl 17OIY
P1VRMTT+'"l Su/Ji7i"I'Zly
_
CONSTRUCTION FEE 101.000.418.000 $1,521.50
PLAN CHECK F'EIr' 101-000.439-318
MECHANICAL FEE 101.000-421.000. $136'sp
4
F.,I.W,TRJC.AL "KE 101-000-420-000 $296.1.1
1'I.,tIA9BINO FEZ 101 �000a419-Cl00
STRONQ MOTION FPE F RESID 101.006-241 -000 $35,14
t3RADI'NQ RIB ]til.0410-433.000
DEVELOPER IMPACT 11 $1,907.00
ART IN PUBLIC PLACL9 - RUIC 701w000-255o0OG S"i .47
WB—TOTAL CONOMUCM014AWD PLA9 CHOM
9.Og
I , , :PRY—PATO IMM
$0.00
RECEIPT
DATE s )
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
d/
Return Air
Steel
Roof Deck
d
Combustion Air
Exhaust Fans
O.K to Wrap
_
�l
F.A.U.
Framing-
_� _
Compressor
Insulation
L _6 _
Vents
Fireplace P.L.
Y,
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. lath
/
Final
Final
%d2- ��d'
POOLS - SPAS
BLOCKWA
L APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Z Z j.p
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICA 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)