0008-128 (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
Ex Date
40974 B
Date Signature of Contr•actor
tractor 1,4
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
1, 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 ST -ATF
Policy No.
(This.section need not be completed if the permit valuation is for $100.00 or less).
1, 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 Califorrfia�,d agree that if",l-IdWd become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, 1,,sha w'th comply with4those,provisions
Date: 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
,,- A .
construction, and hereby authorizi representatives of this City. to enter upon
e 11 . I
the above-mentioned property for inspection purposes.
1.e
Signature (Owner/AgentL_
BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
95 294-57-1
JOB SITE APN
ADDRESS
M VWA E STMT.A
OWNER CONTRACTOR DESIGNER EN61NEER
M DF,,9MVr DE-V1;ti0P1vfiZNT SPAM CON SITRTX*n0N
_P0 BOX.) 7 i 6 XWN0.1-10 1A QIJJNTADF-
LA QLTMTA CA 92253 "QUI)m CX 92253
(76OY771.1941 .`,�,,C;LH .29P6
USE OF PERMIT
SMOLE FAUJI-Y DWALUNG
51,M- IXIT15 PLAN. -M3 - PER11hit D09S NOT INCLUDE BLOCK.WAILS DR.
P001. %5% PIAN CHECK FE,9 REKDOICTION FOR MULTIPLE 10SUANCE Ote
SAME PLAN TYPF.
CUSTOM. CONST RUCTICO 4,243,00 SF
PORCH)PATIO' 523.00 SO
OARAWCARPORT (91) 13,916.00
E91311!1ATXD COST OFF Coxmtraffow
mmurr YEE hmmmwy
CONSTRUCTION RX, 101.000-4111000
$021,50
PLAN CHWK FEE 101-000-439-318
$36933:
MECHANICAL ng 101-000,421X000
$136.50
PLUMBING FRE. 101-606.419-0001
$203.00
STRONG MOTION YE RE"31D 101--000-241-000
$35.14
_0
GRADING FRE 101-000-423-000'
$20.00
r; f
DEVEMPER IMPACT PEE
$1,907.00
ART IN PUBLIC PLACES -11WE 701.000m2$5.000
5314.47
SUB -TOTAL COWOTRUCTIOI� AND PLAWCED10C
$4,759.05
Xl= PR &PAID FF RS
$0,00
TorrAllpria"r YPW1qDUF_R0W 11 - . ki-1259.05
RECEIPT DATE BY 1 IDATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs_
Forms 3 zV-0 �
Underground Ducts
& Footings
Ducts
Slab Grade
Return Air
_
Steel _
Combustion Air
Roof Deck f' p
Exhaust Fans
_
O.K. to Wrap
F.A.U.
Framing ���
Compressor
_
Insulation
Vents
`l/��
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Final
Final 4 o'I
POOLS - SPAS
BLOCKWALL APPROVALS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test _L
Appliances
Final
COMMENTS'
,cam
` ,G
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)
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