0006-362 (RC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
4wapter 9 (commencing with Section 7000) of Division 3 of -the Business and
Professionals Code, and my License is in full force and effect.
Lice se # Lic. Class Exp. Date
6991 44 I3. r'
1 $ ' 4W X-
ate • F11 Signature of Con( ao or / �l 1
sue/
OWN ER-BUILDER,DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) I am exempt under Section B&P.C. for this reason
Date Sianature 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 S,TATL, FU14D Policy No. 046-00 0006387
(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
suect to the workers' compensationrprovisions of Section 3700 of the Labor
Code, 1�shall forthwith comply with* those provlsio
ate: %'"� rb .Er, Applicant F",t •/�"/4'�lsr�°cG
Warning: Failure to secure Worke s/Compensation coverage is unlawful and
shall subject an employers 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
constuction, and hereby authorize representatives of this City to enter upon
rr the bove mentioned grope` for inspection purposes.
I Signature (Owner/Age�ntt) Date
&-c2-6_()UILDING PERMIT PERMIT#
DATE VALUATION LOT �' . ' TRACT
JOB SITE
APN
ADDRESS -4w iasmmoxw, , Dim.
OWNER
CONTRACTOR / DESIGNER / EN INEER
1A DANTE, COSGRO ,
D. W. JOIR .ION C0MMUCTION, DID.
1'a55 F,�ONRD
35.688 CA'11.10A L CANYC)N i)YM, 0305
PALM 30t[T+3G0 CA 92261
CA-THEDRAL C1TY
CA
92234
(760)321-9315
CB114
15525
USE OF PERMIT
CiiTddA?#1~`inCM,
TENANT IN9PPOVEMENT MEINCA.L OFFICE
VALUATION 22000,00 L3
ES7.1MATD COW OF CONS"i7i IUMON
PrU2.iUUT FEE SUAMARY
KIEDEP001T . 101-000.439.318
PLAN CkIECX FEE 101-000-439-318 $1,059.50
CUNS TRUCTION FEE 101.000.418-000 $390.91
MECHANICAL i+E& 101-000-421-000 M50
ELECTRICAL PU 101.000.420i 000 $1,01,44
PLUIa§flINO FEE 101-000-419-000 $X00
STRONG MOT [ON F_R, E - COMM 100-(TO.241.000 U6.20
ART 114 PUBLIC PLAC - COM4 701.000-255.000 $1,100,00
MUF3-TOTAL. CUNRI'JC`ION AND PT-a4.14 CIMCK
$:3,:304.53
'I'MA'€, L'MOU11 :17U211 C>bV
,•t 4. '�
RECEIPT
DATE
BY J1
DATE FINALED
INSPECTOR
R
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing "
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath CM. 7 -.,1 1 12 Z-477
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS -
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Final
-,c>d
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
' �!�_ uJ
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Gas Test
Final
COMMENTS:
7 dfiav— Glx l'? d?.
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice (Pe
r'
s
11Building zlq-. L
Address `-� L
Owner /�
Dr- 1)1)J 1a , f
0 4 "
P.O. BOX 1504 APPLICATION ONLY
�p 78-495 CALLE TAMPICO
�ZUi�iCQeILA QUINTA, CALIFORNIA 92253
Mailing V �}
Address /Z �• ��IJIOt9 /�// ,
City Zip Tel.
COAL))) Spf,al 1 9 Z& 4— 141
Contractor 4k_/
Address
City
Zip
Tel.
State Lic.
City
& Classif.
Lic. ff
Arch., Engr.,
Designer
Address
Tel.
City I Zip I State
Lic. q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License 'Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to 'its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provfsionS of Ind -Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3. %the Business and Professions Code, or that. he is exempt therefrom, and the basis
for ''(he alleged exemption. Any violation of Section 703,1.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (8500).
I: 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044. Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
7 I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
r7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (E100) valuation
or less.)
I certify that in the performance of Ing 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 309,7, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and slate that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter the above -
mentioned property for inspection purposes.
Signature of applicant Date
.Vailing Address
City, State, Zip
11LDING: TYPE'CONST. OCC. GRP,
P. Number
Project Description
Sq. Ft.
Size
No.
Stories
No. Dw.
Units -
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
—�2SO • OO
a-) .—
Plan Chk. Bal.
Const.
Mech.
2 , Q
Electrical
In j ,
Plumbing
4,q.06
S.M.I. — G4160-20
Grading
Driveway Enc.
Infrastructure
AtPP-c,oxk%_
W 00 •DO
TOTAL Vk L.
1J
REMARKS
!CAI
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by: -
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION