0008-124 (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
Date'"./,. "' Signature of Contractor % ^' ✓
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 3700of 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.
1 A.TR i�B.?4I�3 Yi9o-pi141335
(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 h s provisions.
Date: rfi < 7, , ' Applicant/ N.
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 agreetocomply with all City, and State laws relating to the building .,
construction, and hereby authorize representafi s of this City to enter upon..
the above-mentioned propertyfor inspection urposes. �.
Signature (Owner/Agent) �fy � ..Date
BUILDING PERMIT PERMIT "����,
o��y
�0IS�ryy-0a�
DATE • VALUATION LOTTRACT
1 le 91 29457.-1
1 t i1'Et
JOB SITE•i
APN .
ADDRESS 49-21.5 VIM bTRFJJA
.6494 OW
OWNER
CONTRACTOR/DESIGNER/EN INEER
ED DEEM Y1 DF-VE%OPMFi,W
SPARKS ownRUC'I'!ON
PO DOXI V r
79-25" RANCHO I.FA QAJMI TA DR,
1A QUWA CA 92253.
1A QWNTA CA .92253
•
�160j'171-194:1 Ci�I.�6 299 . .
USE OF PERMIT
MINGLE 1 Y Di1V.I L3;F1 16
SM LOT -01 PLAN 11438.-,PFRMIT DOES 140T INCLUV 81-OCKIVA,LLS OR
r OOI.. 736E PL A)4 CllisivY�;F `t I;CiUO' IOPi Fok MuLTIPLS 188LIA-air, OF
SAME'PLAN •TYPX
CUSTOM CONSTRUCTION 4,243.00 V
Ijokcfl/PATIO ' 522.00 5K
OARAWCARPORT (ff) 13,916,0.0
1!t`S'.d: IA7E" COST OF COI`l'19TRtTL`` ON
$?'ERwrM si.Tmv.wy
CC1dOTRUCTION FER 101.000.418-000 $1,521.50
r,
PLAN CHECK FES 1101-000439-316;
MECHANICAL FEE.. 101.000.421.000
=
ELECTRICAL FEE 1 QI -000-420-000 $246,7.1
PLUMBING FEE'.- 101.00019-000 $205.00
STR:t: NO tAOTION MS - RIa: 0 141-000.241-000 $35.14
GRADINO FSE 1.01.000.423.000. $20100
FriiJ
I91a-IKLOPER IMPACT FES
ART IN PO'BLIC PLACES - RF.31 701.000.255'-000 r SM.47
Sir-TOTAI, C0XfffRUCT.I0Ai AWD a?I:FWa. ClItCII'
$4,759.05
ASO PR.E-PAM MS
$0.00
TUIAL FEMM FEES DIM NOW
$4,7159,05
RECEIPT
DATE b _
BY r�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
_
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings'
_
Ducts
Slab Grade
_ All-
_
Return Air
SteelCombustion
Roof Deck
,��
_
Air
Exhaust Fans
_
OX to Wrap
Framing
Insulation J�
Fireplace P.L. /
/
`r
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
•
Final
Final
— Z
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
�,.
i
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
Sewer Connection
_
< /
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
COMMENTS-
/� k
0
Final e-121
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) C7►