0007-260 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commericing 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 Contract:,r
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).
( - ) 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 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 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 those provisions.
Date: 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
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspection purposes.
Signature (Owner/Agent) Data {
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
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JOB SITE � 4 _'
ADDRESS a
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
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I-POS PRE-VAM FF , 3
4230, ('All
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR,
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs !I 12,fe underground uucts I I
'Forms & Footings _ �Q I Ducts
Slab Grade _ Return Air
Steel I Combustion Air
Roof Deck #/ _ IP7
Q.K. toWrap/.��
FramingG`
Insulation V�
Fireplace P.L. I
Fireplace T.G.
Party Wall Insulation
Party Wall Firewall // C
Exterior Lath
Drywall - int. Lath
Final I
Exhaust Fans
F.A U.
Compressor
Vents
Grills
_
_L
Fans & Controls
Condensate Lines
Final
—
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
j
Set Backs
_ -
Electric Bond
Footings
tAain Drain I
Bond Beam {
Approval to Cover
Equipment Location )
Underground Electric
- -
Final _ _
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
Gas Test --
+
Electric Final
Waste Lines �
Neater Final
Plumbing Final
_
Water Piping { _
Plumbing Top Out {
Shower Pans 1 I
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral
I Pool Cover
Encapsulation
Sewer Connection
./L/_ ..
COMMENTS;
Final I I
Utility Notice (Gas)
ELECTRICAL-
Temp. Power Pole _
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
(Perm) j .L v ` -) I /' "-
4-
ip
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78-495 CALLE TAMPICO
LA QUINTA, CA 92253
(760)777-7075
APPLICATION
FLOOD PLAIN DEVELOPMENT PERMIT
FLOOD ZONE PANE - DEPTH 1
BUILDING SITE LOCATION
COMMUNITY- PANEL NUMBER
060709 0005 B
l } Map Revised: 8/19/1991
APPLICANT INFORMATION SECTION
APPLICANT NAME D 5 C-t re3-•r fP '
APPLICANT I'' —l0�' l S VvtCt Y r S4
ADDRESS j1 % I �
(MAILING ADDRESS, NOT THE BUILDING SITE) ��' 1L3 '1 o `/�^ a _ 9 Z 0
DAYTIME TELEPHONE NO. 3 — O I y L�K� �LA ���' —
INSTRUCTIONS
1. A Flood Plain Development Permit is required by LOMC Section 8.11.040(A). The Applicant should complete the
Applicant information portion of this application and submit it to the Engineering Department along with the
required documentation noted hereon at the same time the Precise Grading Plan is submitted to the Building and
Safety Department for plan checking.
2. Documentation required for STEP 1 OF 2 APPROVAL prior to receiving clearance for Building Permit issuance
• Copy of the proposed Precise Grading Plan for review and approval containing all information required by
the checklist shown on the back of this application.
3. Documentation required for STEP 2 OF 2 APPROVAL prior to receiving Flood Plain Development Permit approval.
Nate, this approval occurs after forms for the lowest habitable floor are set and before the Building & Safety
Department authorizes foundation construction.
• Submit a completed FEMA "Elevation CertfcateE form to the Engineering Department.
• Submit 95% relative density soils compaction certification to the Engineering Department.
STEC 1 OF 2 APPRO sTgp 2 OF 2 AEE09—V—A—I.
The Precise Grading Plan submitted for this application has been All requirements have been satisfied. This Flood Plain
reviewed and found to contain all data required to satisfy the Development Permit is approved.
requirements of LQMC 8.11 The proposed dwelling is eligible to
receive a building permit upon satisfying all other Building &
Safety Department requirements.
C
AUT}IORIZED SI 44E VSIGNATURE DATE
La Quinta Engine 'ng Depa nt Engineering Department
FILE: Upon Step 2 approval, original goes in 'Flood Plain Development Permit file; copy goes to Applicant