0008-121 (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
b?0'74 H �
Date ./ 7f Signature of Contract o 1 t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
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).
( ) I, as owner of the;"property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 1 ./,
() I am exempt under Section , B&P.C. for this reason
Date Si4nature 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 PU't•IFJ Policy No. 44h DGlS73
(Th 'is 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 Califora'and°agree that if I should become
subject to the workers' compensationeprovlslonsof Section 3700 of the Labor
Code, I shall forth vith comply with those provisions+
Date:<r 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.
T. 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 uponT
the above-mentioned property for inspection purposde" j
Signature (Owner/Agent) 4. Dater
r •
BUILDING PERMIT PERMIT#
DATE f 'VALUATION LOT -4''�"' TRACT '
29457-1 . .
JOB SITE i
APN
ADDRESS . 49--170 'flWfA F"RMXA
C49"100-009
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD n1• ° T Dr, MIOPI". .r
SPAR..3 C0.N'8T-R7JC z0N . .
Ya Dax 17 16
79.295 RANCHO LA IQUBTfA DK
LA (xUMA CA 92253
LA QUNTA CA 92233
(760)771-19-41 CSTA 2996
USE OF PERMIT
j
:SIT. 7.0�'.Itli PLAI+;MI • PE T T)C�P.S?•tO INCLUDE BLOCK6b�A�,LS OP. +
POOL - 95% PLAN CHWK FFK REDUCTION ?bbR MU1;,' IPLK ISSUANCE Ott
S MI3 PLAN TYPE;.
CUSTOM CONSTRUt�T)ON %As, ' SF
PORCH/PATIO 590.00 sp
GAPLAOUCARPORT,(srry
T.fiftnKA 770 COST OF C:ONSrMUMO.N
pkl.mr.CFEE, 9uhu"M
�M �^
CONSTRUCTION FES: 1(21-,000.4'18.000 $1,280.00.
� � .tP
PLAN CHECK FEE 101-00043931 (AS�.a3
� '' ��
MECIMIC7ALFTE 101-000.421.000 $149.50
k� ?
ELFC7'RIC .LF1PL� -42 -000 $215.08
gLUMIINOFEE 101-000-419-000 $202,23
'
SCRO40IMOTItY'N IWEE = RI`n9ID 101-000-241.000 $28,31
w '^
0RADINQ KE 201-00.0-4,23'-000 $200,00
DF.V1 Ld7PZR.IMPA.C;T M,$1,9tY� OG
ART I'H Pi,IBUC 1=1..AC ES RESIE 701-000.255.000 $.20127
Si 1F;-T(Y At,. C:OHMIIIZIU ,.TION AND FLW ("BECK
$4,271.50
LMS PRE-PATD Pte?.:
$0.00
' C1'AAlr YK.€ !T 1i EES ME NOW
S4r1715
RECEIPT
DATE f
illeiY
BY " .j
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_ _
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 _Z C
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) YZvz
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)
COMMENTS: