9605-066 (AR)LICENSEUCONTRACTOR. 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
62 H 56 8 61
IDate .0_174Signature of Contracto r
OWNER=BUILDER DECLARATIO
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 37,00 of,the,L�Mor Code, for the performance of the. work for which this
► c1'i' (1 fi ertef:i;F is .
permit is `Issued. IVY workers' compensation insurance darner 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 beco e
subje6t.to the workers' compensation rovisions of Section 3700 rf the La or
14.1
Code, I shall forthwith comply with tja provisions.
/tDate.3' 0-41 > Applicant �'
y,
wWarning: Failure to secure Workers' Compegsation 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 tis City to enter upon
the above-mentioned property nspection purpo:;U1Date,5�/2M
Signature (Owner/Agent) /i v^J
p
PERMITN -• . _ �°NTR°`#
BUILDING PERMIT. ��6 3 317
DATE 5J14196 VALUATION $V1,00.00 LOT TRACT
JOB SITE 55-801f OAK MLL
APN 769-351-026
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'I'I'IOMAS IN & BARBARA l CAL.I. IS'T
INIRTI aI 11TV. CONST UCT-10IN
S580I OAK I L
54705 AVE. CARR.ANX.A
L.A. t; WN'I A CA 922NI
I.A. Q(r NTA CA 92253 . .
(619)564.1274 0BLO 2968
USE OF PERMIT
t1l;:►I')iTION
)U,Tffl1ATICK ADO 2 NEW SKYl.YfJUT5 Wt:NDOWS BACih WALL
CLKIIMii1`Q'ILY]; C09T OF C:ONSv1'YiI7MON
I1101 TO. -W
PS±,ftllO"r IF'EF'81JM-.1V.11A.RY
PLAN 4 -31r -M F Y_ 01-OWU=439-318 $13.1,90
S'f'ONt:rS/!ti'i'tiaKFE3 12�,SLU 1fTI.000-241-000 3i.i�i
—
I
f
SUS-'1'(iI11.T COT�iSi'i?C1C"T.TC�TY AND PLAN "tik C:
�ZU4?.dN!
LESS k`'Tt1-,-,PArD F•F.".�S
S;0:i'ii3
TOTAL PF;.t?t;y IT VU -14 DUC NOW
$209,00
RECEIPT il
DATE
BY
DATE FINALED
INSPECTOR
7
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
BLOCKWALL A OVALS
.POOLS =SPAS
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
Final'
Utility Notice (CM)
ELECTRIC L - 'PROVALS
Temp.; Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 1101,
Main Service
Sub Panels i ' .
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of P ,
Final
Utility Notice (Perm)Udc 14
COMMENTS:
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