9706-022 (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
-Date ����� 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:
Cartier Policy No.
17A'TE F1 IND (,2633346
(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 provisi ns of Section 3700 of the Labor
Code, J_. hl fcAhwith comply with those provi ions.
Date: //� r' Applicant" W--�-------
r'
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 iso.
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 mentio e�d property for inspe to `purposes.
.Signature (Owner/Agen""— Date
BUILDING PERMIT PERMIT# CONTROL#
97116.022. 5 2 9 9
DATE 614197 VALUATION LOT 71 TRACT 28457 1
ADDRESS 7$44) L�'APE, % DRIVI; JOB SITE
APN 609-0144-013
OWNER n
CONTRACTOR /DESIGNER/ ENGINEER
'1711: EX(A 1ANCH GROUP. INC
RIOG ?R''1.1E'LL2.,1BE RGER. & ANSOC.
i F LOREIs 1'iNA DR
41-8o; AOARt)WALK, SUrIl 212
RANCHO hiIkA01V ('A 92270
PALM DR-SE111' (".A 4:21 t
(160)777-7766 C131.# 1858
USE OF PERMIT
Sty[)
51.1) 1.0 r 24 PLAN d A
►RA%"rCONN RUC7 ON z7dx?.ti(1 "IF
fi%_)K01rf1ATi0 110.00 SF
(1ARAGEUCA€2111014 T 4710) SF
rNI'llMXr.Fo cyr or CONSTRUCTION
130,154.60
PM 1tWY FEE, SUMMARY"
0 )NS9'R1 K'I'€QN 1•'W. 101 -000 -418 -ON S7480i
PLAN 0 it?I:IN nIT 101 -MO -439-318 V 18 74
I WKIIANICAL ME, 101-000-421-000 S60.00
14X-.01'RICAI. FtU; 101-t)i*420.000 SI?11.42
PI.UNHIFNC Fj.:� 101-000-4194)00 114) 75
31T)NO M01*10N FIT- - R0 SID 101-000-241-w. $13.02
GRADING M- ' 101-000-423.000 S:0.00
WRA.STR00'11JR13 FW. 225-000-4.13.111 $2.89536
ART IN 111YRL1C PLAC ti3 - RESID 701 -(W-255-ow S7539
110TA1f 0"►NS7RCK" ION ANT) MAN CHECK
$4,706 38
LESS PRE -PAID YEEN
-$2150.00 ;
JUL 01 1997 'roTAL PFRM1'r r VILS OUE NOW
$4,+56-01
e
RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
h
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs j
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 ,S'
Final
Final —1, 6
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
Gas Piping
PLUMBING APP OVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sh
O.K. for Finish Plaster
ewer La eralZmgz Lf
ewer Connection
Pool Cover
Encapsulation
Gas -ping
Gas Test —�
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS,Ji�G��'
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: