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�r 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
59.1a4 C-29
Date Signature of Contractor
OWNER -BUILDER DECLARATION
4130/00
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).
(A) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)..^
O am ex' mpt n er Section , B&P.C. for thJs reason;_,_?
dDate \N' Signature of Owner f ' a7 L
� � is
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.
( ) 1 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.
LEGION TMS CO WC 1065323 y
(This section need not be completed if the permit valuation is for $100.00 or less).
�Y,) 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
C de shall fo hwith comply with\those,,pgovisions.
ate.�� i �/ Applicant--�..�r 1/_
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. s
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 tol
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 t ove-mentioned property for inspection purposes.
Signature (Owner/Agent) t"-+ �L I /I �•/i�%L -,Date
DING PERMIT ' •� ' ' PERMIT# ', .: , I ' • . .CONTROL#'�. ,. .
" • • a
'TRACT'
,BUIL' 4i
DATE VALUATION LOT •
91/25/98 $2,500.00
JOB SITE
APN
ADDRESS 51••515 AVENIDA OBU..',GON
771 LI -01 i
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JACK. CLARK C3ENERAI. CO" TftJkC!T i!Z
HAMILTON tiMASONR Y
54-350 AVENIDA HETUU,R.A
?3165 BE1. A1R POiV7, PAL1=i DESERX
LA QUINTA CA 92153
L'.A QUINTA C:'A 92253
(760)34:5-7653 C B1,1t 1631
USE OF PERMIT
GI NERAL RUILDING
100 L.r., 6 GARf-.}E'N WALL, ORCO SYSTEM
6 Ft. WALL 1M.00 L;+
ESTIMA'Y"E D COST CDS' CONSTRUCTION
PERMIT' FEE SUMMARY
CONSTIZUCTTCYN FEE 101-00U-41FC- 00 $54.00
AID., C0Nk-TRI JCTON AND P.I.-A N C'.! -{F. -CK
LESS PRE,-PA1i.7 !°FES
sT.).00'
AUG 2 5 1998 11
•rf.I.9'e18.,P, EIdMIT 1+ IEF-S OTTE NONV
�lTY OF LA QUINTA
RECEIPT
DATE$ A6
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade i
Return Air
Steel I
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap }
F.A.U.
Framing i
Compressor
Insulation i
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation i
Condensate Lines
Party Wall Firewall I
Exterior Lath 1
Drywall - Int. Lath I
I
4
Final
Final r
BLOCKWALL APPROVALS
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings I
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL
GasTesElectrFinal
Waste Lines I
Heater Final
Water Piping I
Plumbing Final
.Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection !
Encapsulation
Gas Piping I
Gas Test i
Appliances
i
Final
Final I
Utility Notice (Gas) }
ELECTRICAL APPROVALS
Temp. Power Pole }
Underground Conduit
Rough Wiring
Low Voltage Wiring I
Fixtures
Main Service
Sub Panels i
Exterior Receptacles I
G.F.I. j
Smoke Detectors i
Temp. Use of Power I
t. }
f i
Final j
IEltitity Notice (Perm) i
COMMENTS: