9706-023 (SFD)LICENSED CONTRACTOR DECLARATION
I heretiyaffirm 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
/2
Signa17i3U97
ractortue�on
r
OWNER -BUILDS DR ECLARATION
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).
( ) 1, 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.
`l' 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.
STATE ,FUND 626351%
(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 th workers' compensation provisions of Section 3700 of the Labor
//ode, hshfo wi comply -with those proves ons.
Date: �� (r � Appli not
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
e above-mentioned property for inspection purposes.
Signature (Own Agent) �`'�"" Date
_J X
BUILDING PERMIT PERMIT# CONTROL.#
170"23 5273
DATE *14/97 VALUATION 1141,20.4# LOT TRACT
JOB SITE ADDRESS 7&67§ NAPt,XS DRV , "
APjN0 13
_,,�q �{
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JIIEi E:XC11ANUE GROUP, INC
K(MER SNELLENBERGEK A`. ASSOC
I FWREN'11NA 1)k
41-80 BOARDWALK, SUrl 212
RANt:.'.H0 MIR-A(fly: CA '42270
PALM DESFRT CA 47211
(7601777-7766 CALK I"
USE OF PERMIT
8FD
'01) LO'C 4!11 MAN SH
TRACT CUNSTIti; TION '4400.04 .3
N)KCIWA'I'10 1WV0 .IF
0ARA(WC'ARNc)RT 44901 HF
. ESTIMATED COST OF CONSTltUC110N
141,MAQ
PERMIT FEE S:S14fiki+1ARY
CONST! I K11 10" FM 101 -000 -418 -OW $786_%
PLAN (14" FFE 10140)-4:19-318 W7.91
NUICHAN1CAL FU 101-000-421-M 360.00
W.EC'1'kt1CAI. FEE 101-000-420-wo $141.48
P1 tfWfW4 FEE 1014)00-414-000 5144.75
STOW) M(MON FFH - EiFSff) 101-044-241-000 514.12
GVAL3NU FEE 101-000423-000 120.00
INk'R"itwrLwE wu 22.5414t)-443-342 ;.130.21
ART IN KiBLIC PLACES - USIU 701-000-2SS-040 $103.12
PLAN 0F*4,'K FW 101-004-4-49-318 -1485."
EC7I :AI, t`'CNJS" (_K. ON A_ND PLAN C BECK
S5,044 439
LESS PRE -PAID FEES
-5485.93
1997
Jul- O 1
TOTAL 1'YRMIT ",1�1 DUE NOW
$4,W.16
RECEIPT
DATE
BY'e
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade A
Return Air
Steel 11K, IV,
Combustion Air
Roof Deck i
Exhaust Fans
O.K to Wrap If
F.A.U.
Framing sti
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 —
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 APPOVALS
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 7110171
Encapsulation
Gas Piping
Gas Test - OZ7 >pt
Appliances
Final
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)