BLDG (9608-041)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,%#jtj al Lic. Class Exp. Dalp,
r•
I DaIe'Py Signature of Contractor—
OWNER -BUILDER DECL RATION
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:
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 ifI�should become
subject to the� ork ►s' compensation p�r.o,Y isions of ectio 37 • of�the Labor
Code, I sh I'for . ith comply with thosovisio
L_Date: , L Applicant _
Wafning-,4-ailure' 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 rep sentativ � h'S C4 to enter u on
the above-mentioned property for ill P Poses?
Signature (Owner/Agent) ate , f
, 2/,,BUILDING PERMIT
PERMIT] �� ,� � .
CONTROL#
3855
DATE , VALUATION LOT
. . TRACT
-.
JOB SITE `r• r rs, v ,rat �_ wa'a a sa a. a
APN
ADDRESS
V
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Nit. NTIRRO.t=5!-ATES
ED 91 PIZELCZYK :
7� 483 C &LL.E HUl~`lt'IA
92-231G 1k91' .HE.L10Crt
I:A-Qutmr-A, c'n 922-53
INDIO
CA 92201
347-031*
CID 0
USE OF PERMIT,, .•� i ��•yy CC a'{(
6 FT. WALL
314.00 IS
�';i3'!�."ri'�t3c�'1��i�?�i rfir'f� �t7i.-Ut3ti-•91&i)t!(.). �?�if)rt
fi 1��13-'� t� 9°�! C, l:+ JN �S FIS Ll i�d ►N .1+. t+71' �'� ,A1V �" I � K.
$25.00
LESS l=i".t-145Aal FE Es
$(koo
S
AUG 12 1996
RECEIPTi7" - N
DATE_
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
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
Bond Beam /
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final j
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
FinalB�lf-
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:
4
P.O. BOX 1504 No. 06700
Building 78-105 CALLE ESTADO
Address 49-450 NOmero LA QUINTA, CALIFORNIA 92253
Owner ,
He=y.
Mailing, 6 HeBUILDING:- TYPE CONST. OCC: GRP.
Address S"e A.P. Number Hontero 88LeteS
City Zip Tel.
La QlAnta 92253 Legal Description
Contractor Project Description Carden Wall 34' $t' X 6'
_H.P. Pinson Bros.
Address
85--624 Wle Lium
City Zip Tel.:,
Coachella 92236 39$_6798..
State Lic. City
& Classif. 7 Lic. # Sq. Ft. No. No. Dw.
Arch., Engr., Size Stories Units
_ Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that) am licensed under provisions of Chapter 9 (commencing with Section
7000) 01
Division 3 of the Business•and de
Professions Co, and my license is in full force and
effect /440M, %
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL SQ. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
METER LOOP
HEATING (FINAL)
DRAINAGE PIPING
CAR P. I SQ. FT.
GAS (FINAL)
WALL SO. FT. @
DRINKING FOUNTAIN.
SQ FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
�
FLOOR DRAIN
MECHANICAL FEES
GRADING
cu. yd.
$ plus x$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER, B.T.U.
SQ. FT. ® c
BATH TUB
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/a c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF. �Z n
T
�C�
(ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
�
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINITIALS
'
GARDEN WALL FINAL
i