0012-097 (SFD)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
714188 B 10)131/2(
D tem f r Signature of Contractor y v"�-
�,. 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
WOR KER'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 mairitain workerscompensation insurance, as required by
Section 3700 6iA4' a Labor Code, for the performance of the work for which this
permit'is issued. My_ workers' compensation insurance carrier & policy no. are:
Carrier GOLDENIar�C3I,E lN."� Policy No. t�L �R4vd3 A2
(This section need not be completed if the permit valuation is for $100.00 or less):
O 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 Sectiori 3700 of the Labor
Code,1 shall forthwith comply with those provisions.-
Date:
rovisions:Date: i Applicant f'
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 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, tr
& 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..
Si riature (Owner/A ent) r .^ r - Date t
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 001.2A97 TRACT
23173.5
JOB SITE
APN
ADDRESS
W91 0 WDRWO STAR, WAY
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CM`LiRT CROWEU., t 0k&A(TY1riU0
1`0 DOX 5140
1535 30. 4200
IL' W.PORT BEAr. . CA 92662
eSAWBE+RNKRDiNO CA 92408
(909)381,+6007 ("aw 2120'.
USE OF PERMIT
SINGLE`' FAMUX DWE WG
SifF.S4iAN "O i.OT 50. IT WT:5'kfOT WCLUDEr
IPFA
BIWWWALI.,POCtE,,d'L►RREWA Y APPRZOACH, eS %PLAN CHECK. FE
RE4I)LIC' ION POR € UL TIPLE MSLJ.I INCE O'F'SADAE P1,AN TYPE
TRACT COWSTRUC: ION
IsORC; HIPAATIC)
CLIkRAWCARPOU (13f);
A1z INXF.D.C-OWS OF CtJMMUCnON'.
nv,7:E9.30
FRIvW.A.'YEN 5ti3mmiii'
PLAN CHECK Put 1L11�t30103*a13S+-5'131 $1+�I;�tt
URANiCALPRE
'LT C TRICAL 2iirL?.. F C?l •E�A4-'I QtJ£J �i i:t.:7f
PL,I MRNTCi FItI? 101-000-419.000 $,134,7$
STROAiOl�f,�'TIti28 FEP - REr D. 101.-UD0-241-0 00 $1117
I31'IAU1110 FEE 101-000«423.00-0
DEV !'I. VER IIkIF>ACT %moi► $1,967.0
yyC)�ylid,Lt�9•��jjC���3��j/�yq���y. �y�g�p
pp • ! 7 IM_I�'i"d`e.:.4J d°a3Jt:r�:T
Q3�(���
�W I N
JAN: 8 2001 TMAI MAW..� � ;� UN.- OW
-'17 r luf 'LA•UQ XAI
RECEIPT
DATE. S t H'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
��_
Underground Ducts
Forms &Footings
y—z C�FrB
Ducts
Slab Grade
b
Return Air
Steel
_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_8 Q
F.A.U.
Framing
_
G
Compressor
Insulation
� � j��J
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
POOLS -SPAS
BLOCKWALL APPROVALS
steel
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
`L �(—�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
2,
Pool Cover
Sewer Connection
?�ZZ ���
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
ea
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)