0008-131 (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 i' > ^ Signature of Contracto /
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 .
O 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 STATE F'U'ND Policy No. 04"00'338
(This section need not be completed if the permii'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 1=should become
subject to the workers' compensation provi Is ons.of Section 37001 of the Labor
Code, I shall forthwith comply with those provisions. ,j f
Date: 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 forinspectionpurposesf
Signature (Owner/Agent)1 Date
- r
BUILDING PERMIT PERMITN
($0€38••1.3Y -
DATE VALUATION M Csd26.0 LOT 70 TRACT 29457-1
JOB SITE /
ADDRESS 49_= -VISTA 1pAPN
-
£�9-lC3t?'^tYt3�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PO BOX 1716
.79•_2,,95 RAN'C:IiO LA Q'CT�I`S'A DR,
LA Q. TA'C,A- 9225.3
LA QUW.r A. C4 92253
(700)771-1941 OBIA 2996
USE OF PERMIT
SWOM I7ANfll�'.Y D•UVk-1AW
SOD-1.f3`P99 P1 A2d:MIR ' PERMIT, !'DOES NOTINC1,UDE bLOC.KW..P.I.LS O
POOL,. 75% PLAN CHECK K 0_3Z REDUCTION FOR MULTIPLE ISSUANCE OF
MME PI.AN TYPE
CUf;#7'<. M CCANSTR1 CION 3,393,00 uF
PPRCHIPATIO 0.00 S?
0AR3,AGWAOCIR4' (OF) 13'534,20
1+,UIT AA71 M CC3n Or Crp.Piow-umom
282,2f1S.00
00113 RUCTION X 10.1-000-41181-000 IL 80:00
PLAN CHECK PUZ 101-000-439-'338 $36d.i9
SEAI:C HANICA11, h'RE 10,I eO00-X421•-000 819930
EL3�,,C TRICAL n?Z 101.060.420-00(2 $215.04
PLUMBING FEC 101.000-' 41.90000 $202.25
ErYRONQ MOTIO3 i P!_?P, - RESIQ' 101 -ON -241-000 $23.21
C1itA 1 0 � 101-.000-423-000 $20.00
DEVICd.,,OP1l:R IMPACT FEE $1,907.011
AR's IN PUBLIC: PL,7iM - R.ESIr 7411.000w255a000 UK
;M
r f -
h
,p'1t
$x'.31:540 AAT..CO2JOrRIYC1`PON1PHDPLPN(1
$4,271.50
TAESS Pn—PA;T]'% M70
$0.030
TOTAL rF-RWf "MNS D.UX NOW
S4,771 a)
RECEIPT
DATE 1
tt ff'F:.P
BY
DATE FINALED
INSPECTOR
1' kk
i y t...
�J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
' ��� l
Underground Ducts
Forms & Footings
(J CT
Ducts
Slab Grade
Return Air
Steel
Roof Deck
�
Combustion Air
Exhaust Fans
O.K. to Wrap_(
-�/
F.A.U.
Framing
r _
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
BLOCKWALL 1APPROVALS
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
V
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
r- _
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
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Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
11-01
Main Service
Sub Panels
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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