9807-258 (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
6
4780-6 B
Q
ate -1 MAPSignature of Contract r�-4 ✓'� l J µ
OWNER-BUILDERECLARATION
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 isnot 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 (Sea. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
t: 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 ,I Policy No.
(This section r1 e"A Vbe Coln leted if the permit valuation is or 100�b0 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' all forthwith comply with'fhose provisions.
�te:Aye f Applicant
r -
��r 3- �-
Warning: Failure to secure4 orkers' Compensationscoverage is unlawful and
shall subject an employer to(c Ir urinal penalties and civil fines up to $100,000, in
addition to the, cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safety
for a • permit, subject to the conditions and, restrictions set forth'
application.
" 1. Each person upon whose behalf this application is made & each.person.at'
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
i„ &, hold. harmless the City of La Quinta, its officers, agents and employees.
2: Any permit issued as a result of this application becomes null and void if
work• is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building n
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. 2
Signature (Owner/Agent) D/.ri y ` Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 984)7-2.S$ TRACT
11/19/911 '8195.449.20 15 'M45-2
JOB SITE
ADDRESS
APN
77-306iVISTA 1±'.LORA
531,38i> Q72,
OWNER CONTRACTOR / DESIGNER / ENGINEER
KSi. •DESERT RESORTS, INIC IASL LAND 1.1 CORPORATION
.3b-140 PGA, BLVD +, 5. -920 PGA. BINID
LA QUINTA CA 92253 LA QUIMA CA 92253 .
(760)564-7166 CBL# 5323
USE OF PERMIT
PLAN 3 - 5F;D - PEPNUT,DOES NOT INCA—0813LOCK WALL OR P00L,
75%MAN HECK REDUCTION ,APP.L:MD. LA Q'UINTA RESORT HOME- S, .
n
• C.'3.:tSTvN1i.U%iS'1`€tI1G",F14�d^-.,391:015 SF
.
cVORMPATTO 691.06 ST.
ESTIMATED COST Or, CONS' R. UCTIO.N
195,4491,20
'PERMiT ME SUMMARY
CONSIRUCf[ON .ME _1s1 X04-�1I13 004 $975.50
PLNN, CHECK PEE, 1(iR tl00.439-318. $Ltt2 rr$
NXCII[ANICAL ,Ea;B 1 est-'000-421-u0a s1 xs.o
h1;EGtjttCAt, FEE - 101-000-420-404 5141,19
Pf:CMBI[NO'M lot -000-419-000 ' $198.50
STRONCi MOT ION'CEE l21 SID, 101 OW241-004 $19.34
GRADING:F 101-000-423-000 $20.00
—
1;[dN."SYAf1CT(JP.h'F99 225-000-443-342 $4,190.83
ART.IN PUBi 1C, Iq.AC68 }wtiC 701-000-2.55-000 $238,62
:IUI3-`I`O U. CONS17; ICTION AND PLAN CI•iECK
$6,!05.16
' LESS .P1 IR -PAID %RLsS
90,00
TOTAL i'1;J'1.21fs1ff It U&S DUE i 0Ar
S6,105.16
.. fti•`2Al O,e�
,RECEIPT
DATE '
EY 1A
D E 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
Final
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
Appliances
Final
COMMENTS:
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)