9911-117 (RPL)LICENSED CONTRACTOR DECLARATION
I he,�y-=5y affirm under penalty of perjury that I am licensed under provisions of
Chapfer 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. yClass Exp. Date
1/433498 B
53
D to }`"" `� Signature of Contra tor
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:
( .) •1 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:
CarrierT r�!r•�rl!v., 'r n,,141 ,t o . Policy No. r .r. 1 It M) t^ Y
(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
worker compensation laws of California, and agree that if I should become
subj et to the workers' compensation provisions of Section 3700 of the Labor
Cede, I shall fou�rt.h,,.ith comply with fhose'provisions.
,,Date:. ? '_ 'Applicant '�-_`
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject ,to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
constuction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent � i�"`� Date If t <'
BUILDING PERMIT PERMIT#���
DATE VALUATION .Mf. 1 1,40.0 LOT �L TRACT
JOB SITE f 13-645 NAPIX, DX, S DRIVE
APN -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
(?/ N'"yt'rA tiA7I 4 f t,102S SO �y`'a) �.[.Nr A !N0tr.
ltorJKU.)n tM 191L AN,
UT.> TCT1—,ll, tla�.l�a
1861,5 NAPIRS .DRIV;E
Pk), BOX I314
LA qJINI-A CPA. 921,751
PALM DESEWl' CA 927,61
f7tz4fA tCj; 49ti:3 CBLO M
USE OF PERMIT
V4.)01, ANLVOK WA,
Pt30L'AND SPA -0;L -V - ALE` RAISd t�A#t2PJERS Vii.", L 113141fit PLACE AX PRE
PLAI,S'71-X
I +A, f PLD1M 33PA 11,400.00 L
} .4EST1I',.lfRAM•.5_D 4-Vh,'yT Y+i$! 4.4.91,�,4.f•dR �J i~t �L'(�a
:i:kf '4Y.l9il
FERMit F0.b.�I`.S�Jt`�'�A&RY
PLAN CHECK _12. :7Ua-000439-318 W-75
NIS' iu.M(1r VFF !014110fY418.41*0 SMAI)
E1r0'I1ANIOAL FM -- P00L 101-M, _121-000
ELECTRIC A.L HM,.-- KAX W.1 -M-420-000 &15,0
f'5X`lvW[i'Sf,9 VER $21.00
SIJA-'trfrAY, c.10N'1MP0 t ;P0lei SND RII.A:N CHFC K
5319 7S
LESS PR.'P.-'.AID FEES
$0.00
TOTAL PERMIT FEFNDUC, NOW
$318.75
RECEIPT
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
0. 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 I
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Electric Bond
Main Drain
Z �S
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_
—gyp
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
`®'0
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)
Nov 10 99 10.13a
OCT -17-1999 _3:2:7
!F�
Rita Pursley
FROM POGEP. SNELLENBERGER
r` A RE INSPECTION FEE OF $30
WILL I E CHARGED IF THE APPROVED
PLAN AND JOB CARD ARE NOT ON
THE 31TE FOR A SCHEDULED
INSPETION.
I - I I r
NO EXCEPTIONS!
CITY
BUILDI
A'
t. FOR
�� DATE ]2
A-1--
760-674-1666
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760-674-1668 ..... ....................... p.2
TO 96741-668 P.03
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