DEMO (9902-007)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
tiih'i's � C:21. � &I3 i/tii
Date C ',t 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 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:
Carder }#�'�Yt .RY'iT� P+0 Policy No. ,S, .i�,L{)Q.}+A
,i.S.;�t.A ttJ'.� V 1: V�-1. V 1. t, 9Y _ A1:d.M3 1
'k0.
(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 orthwith comply with those provisions.
'a
ate: < 'Applicant f+ j
`Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold,harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
,I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection;purposes.
Suture (Owner/Agent)' ! i' It Date
V% 4 7 i. r
BUILDING PERMIT PERMITI�>�tlr
DATE VALUATION S.J)O LOT TRACT
SITE APN
ADDRESS 55-475 'Rti(�EE767-330-068
OWNER CONTRACTOR/DESIGNER/ENGINEER
T?,QY rtvin' r I11.?A:�97%YTf'�d'�F?iJ ri.4170 V T A'hft'Vl$ (,'ADNJ
aLt�l.i 9J l: i l,ii,1A,./t f.Y l.e3w s 4� lY.i ♦ ltf (. tt. i lsf E.lt 1)R 4r}.{'i..xil : s
LA QU1NMA CA 42253 INIXU !OLLS Cts 92241
(7601345-4746 1181111 19
USE OF PERMIT '
rAW 3s: I ION OF Ft AWY) S`I .ttEiCi"ORE 1't*,41..UZ
t A" `7lo.i' q.q'PX;=(► J-.GNr.J-1r «y �'�fi�ilW?`iyii��7'Xi,tr`►'NY i
0.wr7' w.L4at:TFfi•1'rS1\:.{J-,O.t b' .VA ��.14i, + i.X'•EE....Lt\ }�.
10I.d}fW-423-00i4 ,Qit
St.RM—P'AL C1"tM,<STRUC11:1N r'#.Nttt31{{•'1..-AN (71,1130K{± 45.x/30
S 10PIX -PAID
EGEIPTYIY DATE BY ° DATE FINALED INSPECTOR
iota, �n i X16
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 APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
991
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
0. 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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
.:..
Cit of La Quints
Y
...
Building 81 Safety Division
P.O. Box 1504
.:::
P:eriia,f::::<:>;::><::::<::<:::>::::>:::::`.'< »::
78-495 Calle Tampico
;.;:
71
La Quinta, CA 92253
.:.:.......::::: ::
Building Permit
Application and Tracking Sheet
Project Address: • — '
Oe, . . }-
Owner's Name: •
A. P. Number:
Address: a
Legal Description:
City,ST, Zip: e��(
Co ntractor: • � c
Tele hone:
P
Address:ffilDProject
Description: •
(/ --µ
City,ST, Zip:at 1
OL.0
h ne:
Tele o
P l
IF.......................:.................
R4 � 2
l c uGv E IT '1Z
State Lic. # : •
Ci Lic. #:
i au L S t t'� �a c
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
€
Construction Type: Occu anc :
YP Occupancy:
State Lic.
Pro'o
ecttYPe (circle one): New Add'n Alter Repair Demo
Name of Contact Person:* ��
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: • 1. ���.��}`
�� 7 1p
Estimated Value of Project:
SOUTH COAST AIR QUALITY MANAGEMENT DISTRI T
t �•� NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E. CODIev Drive. Diamond Bar CA 91765-4189 19n91 3gr;_9nnn hlrn•//www anmri nn„
AQMD USE ONLY. SCREEN BY RECEIVED
COMPLETED BY6 Fly)_L,(LI.COMPANY
POSTMARK ENTERED BY NOTIFICATION #
DATE CHECK # FEE $
PROJECT #
NOTIf (CATION TYPE ORIGINAL REVISION DATES
. REVISION OTHER (highlight) CANCELLATION
. i
PROJECT TYPE EMOUTION ORDERED DEMOLITION
RENOVATION (removal) EMERGENCY REMOVAL PLANNED RENO (annual)
SITE INFORMATION SITE NAME
SITE ADDRESS
CROSS STREET
CITY La QvoaAv�_ STATE ` +
ZIP COUNTY K4 u_�
DESCRIBE WORK LOCATION k'V
BUILDING SIZE (SOFT) NUMBER OF FLOORS
r BUILDING AGE (YEARS) NUMBER OF DWELLING UNITS
BLDG PRIOR / PRESENT USE
COMMERCIAL HOSPITAL INDUSTRIAL Other ICE PUBLIC BLDG. RESIDENCE SCHOOL SHIP UNNICOLLEGE
SITE OWNER C1L - `�ryur, 4 Cup.
ADDRESS
=9Tyu-STATE Qr ZIP C CONTACT e� /l r� PHONE
i
REQUIRED BUILDING
INFORMATION
ASBESTOS YES 0 ASBESTOS ES NO
PRESENT? SURVEY?
ASBESTOS YES NO
REMOVED?
BUILDING TO BE YES NO i
DEMOLISHED?
PROJECT DATES
START (C cG�
END \IFT (a
� WORK SHm/pm)^� •/►�
ASBESTOS AMOUNT TO BE
REMOVED (in square feet)
FRIABLE
CLASS I
CLASS II
TOTAL REMOVED(add row)
ASBESTOS REMOVED FROM
SURFACES
PIPES COMPONENTS
DESCRIBE TYPE &AMOUNT OF
ASBESTOS
ACOUSTIC CEILING
LINOLEUM
INSULATION
FIRE PROOFING
DUCTING
STUCCO
MASTIC
j
i
FLOOR TILES (VAT)
DRY WALL
PLASTER
TRANSITS
ROOFING
OTHER
(describe)
CONTRACTOR INFORMATION
CSLB LICENSE # Lf- �
OSHA REG n AQ!.!D ID #
NAME
ADDRESS
CITY �V \ 1 _ I I STATE ZIP SITE SUPVR "T , L PHONE �b
171 1.
WASTE TRANSPORTER #1
LANDFILL
ADDRESS
ADDRESS
CITY STATE ZIP
CITY STATE ZIP
Rule 1403 and NESHAP Asbestos Notification Form REV 9706201403FR97 Page 1 of 2
Fomu, in;Vucaions, and the Rule 1403 can be obtain via FAX -BACK by dialing trom a taxphone (909) 396-255C x Ulmuyt: 4Gt,11) wet .Mv. hnp./(www agmd.guv/prrlfaxbaCc.html
01/05/99 12:09
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