9707-082 (RER)LICENSED CONTRACTOR DECLARATION
;I -hereby affirm under penalty of perjury that I am licensed under provisions of
%. ofer-9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Licerise_# Lic. Class Exp. Date
Date,.- z Signature of Contractor.
OWNER -BUILDER DECLARATION J
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:
CarrierPolicy No.
C"Y` t'i°I,^ Y'1.fA+1 ., �'lp.t.,'•. Y-ifr I .v`+e: r: n: i} q..�!j
(This section need not be completed if the permit valuation is for $100.00 or less).
(XI 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 3 700 of the Labor
Code, I shall forthwith comply with th se provisions..
Date: �� r Applicant _A • ! /*_/_/
sem- r _" y7 ;P_
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 propertyforinspection purposes.
(,Signature (Owner/Age1t)-,7_-- �f��- -�r�"1 Dated'.
BUILDING PERMIT PERMIT# CONTROL#� �' •:.
.-.2
DATE � VALUATION ��{'}. �,;��(s�.i LOT TRACT
r
JOB SITEAPN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER'
'7{ i 1;{{:fit 4 L.9/ ( t"T•r' ?
l I•F S.f i�'I t•t�.r `t%' i.�l.i. r.i .. i 1: �.
L"L,'i`r'• {? 'i ``a'a! ��' '(9A �j ry..:!"�'�AI
/t S .1•.r �..�.i�t. i, l .. ay� •� jti. :1.. 1 a1��.v
lv:►t7i k :i;�.1�C"I� t it ;�';3'
`.a:i +� AVEl'tiIDA RLUPk)
'.I'A RJ.A.N1A, -i.'A 9_!Y*
L.AQUtiN'TA. CA. 9.'2153
USE OF PERMIT
C;!fdbiAti t:..h,i`t!C.dMi iiAiC m;i TC, 0 [ IN0 FI.M i t%A . rki.6 N -ENV 0,'
S,„F. (4A)9LA( it.; .
i i rY.l•L: \4,F!„s�_iFl t'l.�” �.J1E I' '��".4.�(i `:�i�
c:.`i, + ,- W "3;s (jet Si"
a >b�t k `ii tris I” N'N' i• f 0 l' y�.1 z.1. 10
9 .a3ito�n.r s.lSia I a_�ilti =@ami .1. 101
349" s ' n.
W.�.ir.
N Aye
ii a.; \ id ;:'}fit �r. '.�Pi,t' !".>••; 4 A/ � -4,ii i�`,)-:I ,'�- .4 � 3'i ?i ? pCv• t i
t'i =�`i:'f�,•iTE'q`te'i?5! f:;;1; -_. {Phir^t'rtlfl..li3`i'-1'7�s(1 ti�4{ tNf
Ml-� 'f :.a`ii+t ii."r111 YTi''-'. i01 Oft 1!2 000 ai`••.,.:;:
f,d.f5� "•ftt•ti.'lif, 1'iSi< 9t1>UiJ�)'•4�1t•Cgx,r :n."b�' .'3i
110 iA•tE(kitt t !;►:,►": I{i�.-t3%ui_ti I'a•�tN� wiit.t?r'CIO
s 1't 0440 M1tu;'VVP II`'({ r;if N`I,*'A!f) if)t-(1fN tr4t•tiL)s1 %1 IV)
r -
C%
f�
Im
.�cFBr
ANO f -'f WN ("fL6:. !;
VO4 AJI, #'1434f 41T rl.*. *�s 044, Vi?W
a4: Eli;
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
ni
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs qyUnderground
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 APPROV LS
POOLS - SPAS
Steet-
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 (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low VoKage Wiring
Fbdures
Main Service
RSub Panels
IExterior Receptacles
IGfil.
ISmoke Detectors
IkTemp..Use of Power
II Final
io Utility Notice (Perm)
COMMENTS:
Coachella Valley Unified School -District
P.O. Box,847"Therina-19 CA -92274.
(619) 399-51379_ Eito 235-.
TUN Box Mir-Dishictlisi Oidv
DISVELOPER FELS PAID
AREA:
AMOUNT: RCPiJP
CK. "I MSH:
DATE:
I
C ' CATKbF COMPLIANCE
ERTIFI.
(Government Code,530180)
Project Name: Difte: July 23, 1997
Owner's Name: Thomas'..,V. Cal] lister Phiine No. 771-i0
Address: '55-801 Oak,'H441 "L& Ca .,92253
Project Description: Room Additibn'A Garage:
APN: 769-351-026 Tract Lot #i
Type of Development: Rtsid . ential XX Commercial z Industrial
3j9Room Additi6n 537 Garage
Total -S: uare Feet of Building Area: 875
ie
Certification of Applicant/Owiners: Thepersons!gmng certifies that'd * i.tbove-information is correct and makes this
statementement under penalty of perjury and furtherfurtherre,preg represents is auft
nts that'lielshe t r1i d to
sign on b - elmlf of the own
Dated: Signature: v U
V
SCHOOL DISTRICT REQUIREMENTS FOR 'THE _ABOVE PROJECT HAYE, BEEN OR WELL BE
SATISFIED IN ACCORDANCE WITHV&� TE09FOLLOWING (CIRCLE -ONE):
Gov. Code Gov. Code Project Agreement Existing.,
fing-. Not subject to fee
53080/65995 65970 Approval prior.to 1/.,1/87* requirement.
Number of Sq./Ft.
Amount per. Sq/Ft.
Amount Collected
,875.
Lo
-0
ii
Note: Pursuiint.toIAB-181, RobrfilAdditions
ip
for- 500` A: terrr, arp Pkpmpt- frogi_!-z-o-,
developer fees.; Garages arepalso exdmgt.
BY: Foch "Tut" Pensis. Assistant Superintendent-Adrninistrative Service
Administrator-inCharge.'
Certificate issued by: Marep'la Va1&7 Signature:
effective fizi. 1. 107, district provide a written notice to
NOTICE: Section W020 of Om Government i�hide inhicted as Assetubly Bid 3081, set forithsi duhpw,5iq, Stoo�hfglet* ofC
We project applicant at the time of payment of school on do ary, pr?tcst,u� regard to such amounts z1,17V=d =-f., accordance with Section 66020
of the h3overnment Code and adw apillical to law.commences with such payment oiperfocdiam!c cf*Y'_o'dmi requiieiuent as dcscnW in Section 66020 ofthe Uovemmcnt Code. AdditimL*, t1his notice advises dim the
protest dtchcofinust occur within 90 calendar Jaya theriafter.:. -
Note: AB 2926 and SB 201 fees: are; capped at $1.84 per sqdare foot for all .residential' construction, and at $0.30
per square foot for comme
icial/indukrial projects.
Dev. Fees Disk: ML-c\CerVConLSanL (REV. 1/97)
1:i:1_Y Upr Lia uUiiv H
SUB-LIST
.CONTRACTOR 57 ADDRESS_
OWNER1i' r0j,,.t'fK:49CCtS? 2 JOB ADDRESS kSv�t �C�L
This foam shall bejposted on'the job with the Buiiding Inspection Card at all times in a conspicuous place. -
It is the.
he responsibility of the General'"Contractor or;therOwner/Builder'to monitor the sub-contractors that'
are on -this list .are the same' persons performing xthe work. Any-'changes to this list must be approved the
City, of La Quinta Department'of Bwldin,g;& Safe'ty;; rior to work ,being performed by a changed sub-
contractor.
.�: P .}'....
contractor. Failure to comply will,,result it .a stoppage of work and/or the ,voidance of building permit.