0008-129 (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 B �.�. l,.,07 � 113t
x
Date'' Signature of Contractor
�y s..• S.r—""�.. -
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 Policy No.
STATE 104D Policy .
(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 adree that if, I should become
subject to the workers' compensationap o isions of SectionP3700 of the Labor
Code; I shall forthwith comply withythose provisions.
Date: ,=.` oda r % Applicant
Warning: Failure to secure Workers"'Compp sation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,0,00, in
addition to the cost of compensation, damages as provided for, in Section 3706
of the, Labor Code, interest and attorney's fees.
l
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 o, & 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) �d'y 4'r} + Date'/
ay z
BUILDING PERMIT PERMITN
WWI"
DATE j VALUATION LOT TRACT
L 0 4282,106.00 96* 29457-1
JOB SITE! sI
APN
ADDRESS -1• ,t..l��t���
6"400-M9
OWNER
CONTRACTOR/DESIGNER/EN (NEER
71) DFAD PIr,#'cT VEiila'L',CiPLS1::'AI`C
0PARX211 CGWETIPWICTiON
PO BOX 1716
79495RANCHO 1A QViNTAD&
LA 91JIN"T.A CA 92253
LA QuwPA. CA 922$3
(760)771.1941. CSL# 2996
USE OF PERMIT
919(R.i? FJNMY T? U12 G
Sala. I.,S3T;I1£ PI..A.N.-MIR a PERMIT DOES NOT (INCLUDE BI..Or.XWALLS OR
tom, -4% PLAN alk K Fu Ftmu f TON VOR MJiIDLE ISSL AINC tr; OF
:IAtd1+ PLAN TYPL
CUSITOM CONSTRUCTION 048,00 SIS
POR,CFiii'"10 SP
0ARAOFIVARF'O T GIF) 13,382.80
q
Fsn:h kni) O'osr or CA.I+I".s"�.�I7gITon
i'MWt FEE 90IIAMARY
CCiNOTRUC' ION F +9 101-000-418-000 S1121D'Op�
�.o J ,
PLAN CHECK F99 101-000-439-318 $264.33
MECHANIC:.AL. Fn 101-000-421-000 S149iso
L?LPX Fi2ICAt.I 1Q1-0004211400 2IS,M
PLt MBINO FER 1.01--000•419FOOO $202.25
rri C.. '4
X RONO MOTION FEE• PMID 101-000-241-000
LRAi31NCi F9F101-000-4234100, 2F,c7fi
`
D V•ELOPER IMPACT FFZ�I,�4tl.bn
ART IN PUBIAC PLACM, ROK 701-000.255-000 $205127
SUB t{4`PAI CX.%NSTRUCTION AW) P1." CRECK.
54,211.50
IX, W PAR -PAM IT- =
$0,00
`i`CYL'A1a 3'�+ "? Ir 'b XI 1`YC�1►
IT4X169
RECEIPT-
DATE %
BY e 1,.�_
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Forms & Footings
Slab Grade
Steel
_ / /�
3 �( �"
Underground Ducts
Ducts
Return Air
Combustion Air
Roof Deck
_�
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Insulation
..�•�_ _
"/
��,/d� .�
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior-Lath—
Drywall- Int. Lath
/
Final 2� y(—
BLOCKWALL A PROVALS
Final
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_Pool
7�—�
Cover
Encapsulation
Gas Piping _
Gas Test P//U�F
Appliances
_ C7Wr___
Final
C�Q�MMENTS: .�
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) /' /