9912-0025 (BLCK)54495 Avenida Alvarado
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
291728 fisO'J3I/20f
i
Date 12,12 14?, Signature of Contractor-*' ' + '
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).
( ) 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 l'g.P.x 4.e!3 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 370.0 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.
STAT.0 FUND 229-0:f N T 0004483
(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 thoser_provisiOns..
Date: ell '7' Jae Applicant .410"-r4 /- e'Aot, .4 ..n«*,
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) "
Date 07 > 2 _+^
BUILDING PERMIT PERMIT"
.025
DATE VALUATION ' LOTS TRACT
.`2/02/199 52;11 o.430 •
JOB SITEy
ADDRESS ' 544,t t5A,VEf IDAA.LVA
APN
m -
OWNER
LA QU'.t : 'A PARTNERS . •
51-310 AV ii1OA HERMUDES
LA t111)NTA CA 92253
CONTRACTOR / DESIGNER / ENGINEER
WILLIAM. AMi 'R USS LJ., KEG}RS
45690 JACKSON ST
THERMAL E CA 92274
(/60)394.1200.. CB g 1954
1
;
USE OF PERMIT
GENERAL BUILDING
•
130 LF X 40 LF RIITAININII WALL. CITY STANDARD .
4 rr, WALL 130.00 U
•
ESTIMATED C" T Or CONSTRUCTION
114 ERMIT. FRE SUMMARY
(.X)N rRI.u:.><`I0rr Ft3EE t0i-000•418-000 054.00
SUS-'1TYTAL, CONSTRUCTION ION AM) ') .A.N CHECK.
LESS PRE-P.A11) SEES
TOTAL t':ERMiT FEES DUE NOW
. . igt:3/7I r. .7c1, -,c . r
2AIIMII
'554.00
WOO
$SO4.410
IIIIIIIIVIIIIIIVIIIIIIIIE 36
RECEIPT
DATE f i
BY .....‘6):,-p
DATE FI ALED —
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings•
Ducts
Slab Grade
Retum 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 InsulationCondensate
Lines
-
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
V9
5)
Electric Bond
Footings
/
S 7
Main Drain
Approval to Cover
Bond Beam
/'. 7-97
Equipment Location
Underground Electric
Underground Pibg. Test
Gas Piping
Gas Test
-
APPROVALS
Final/4.0(0
PLUMBING
Electric Final
Waste LinesHeater
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
COMMENTS:
.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)