0111-272 (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
59791.5B .�''��'/ /"rel '7�
59791.5
,D/ate _/ k�' "�� Signature of COM—t^,
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 STATE 'ADID Policy No.
(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 sh*riot employ any person in any manner so as to become subject to the
workers' compensation laws of California,.ar9d agree that if..l, should become
subject to the workers' compensation-p'rovlslons f,Sectin3700 of the Labor
code, I shall forthwith' comply with those provisions-..�
v/bate:
i' %�
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 authdhi; ,representatives of this City to enter upon
the above- mention ed,property for inspection purposes.
/Signature (Owner/Agent) rA'•�`'�— �Date,��°f''-
BUILDING PERMIT PEfiMIT#
DATE VALUATION LOT * •� �' TRACT
12.1.1401 2904-2
JOB SITE
APN
ADDRESS. 004W VIMAdECLUOPLACEr
I JrM
OWNER -" ' -- - -
CONTRACTOR /DESIGNER / EN INEER
1?UMMICK ]DEV.:Lf..'111 qTXLC
MkzM% C:APUTIT.Y3,WO DFV.K."P"ii Q dT
�'.f�,1Cr?C13�!it
���iv�i C+�ti��';�.€�Y•t�:3ai�St��C1�
LAOY)YEA CA 92253,
BE3�.•i?.�UD-ADtJ.OM 'CA 92201
06,D 3t 5-TY55 CIRW A%9
USE OF PERMIT
MOINFAWRLY DWM 134
M-,
aSFD - JT It PI,,A14 Y.l'*Vt'.ITH 1'A 1 T Pl?AMI T D0FS10,01 11401 V,
BLOCK WAT.dA P00.4 0PA Olt DRIVEWA AX°73ROt4fT -
CUSTOM, ¢oherRueITICIN 4553.00 FIr
0FC
17 2001
OEC31IP 602.00 Ss
,
OARAGVCARPORT SP
1�:5N'7('l A CLOS' Off' Co'�a'snarscholf
221.125.1.10
(•�;-�Y�y'pg°g�7�._•-
CONSTRUCTIC04 IME 101-000-418-000 $11066130
PL"T CHEM FEE 101-000-4,19-318 $995.47
Xt & CHA11,XC'�aL RE 101-000-421-000 $137.00
RLW,TP.TC.AL IEEE101-000-4204 0 '
o F.Lw,tMMHO MIMI '401.000.419.000
r09-GOUa241-000
c3R1?a,i?3M PH 101 «floo-4.23-'000 $26.00
DWLI.OPER 11lAPAI CT FE1B• $1,M.00
-
ART IN PUBL40 PLAM - RUM 2704000-44-5-000 $53.13
F'EY, DEPO IT Y O 1-(DCkfl X 9 3 4 m$ J Cf.QO
F1L13..�j v°j°.;4. C!Cst�'iiLiC";C)avT.i�39�T.!'{�".
" :�,/41,45 Cy;t ' ..
TE AL r aM" 17MES4IMKNOW
RECEIPT
DATE
BY/f
DATE FINALED
INSPECTOR y ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
$
Underground Ducts
Ducts
Slab Grade
j
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- Z
F.A.U.
Framing
- -6p y
Compressor
Insulation
- --
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
- u- 0�2
Final
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
((/
Heater Final
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
Appliances
Final
-
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)
COMMENTS: