9706-040 (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
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).
( ).+ 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.
( 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:
Carver Policy No.
STA'i'E FUND 621635596
(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 provisions of Section 3700 of the Labor
'ode,.l shall forthwith comply with ttiose provisions.
i Date: L( / f 'Applicant—
Warning:
pplicant 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
tthhe'above-mentioned property for inspection purposes. !' _
/Signature (Owner/Agent) } Date I 7r, !t 1
BUILDING PERMIT PERMIT# CONTROL#
•l81t23d
E3 �
12/31/97
Date
Signature of Contractor
'OWNER'
CONTRACTOR / DESIGNER / ENGINEER
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).
( ).+ 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.
( 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:
Carver Policy No.
STA'i'E FUND 621635596
(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 provisions of Section 3700 of the Labor
'ode,.l shall forthwith comply with ttiose provisions.
i Date: L( / f 'Applicant—
Warning:
pplicant 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
tthhe'above-mentioned property for inspection purposes. !' _
/Signature (Owner/Agent) } Date I 7r, !t 1
BUILDING PERMIT PERMIT# CONTROL#
- 5291
DATE VALUATION S 141,24K,40 LOT TRACT 28M.1
r
ADDRESS 7X-675 NA111,11;% 0R1VF.
APN 609-0..WO13
'OWNER'
CONTRACTOR / DESIGNER / ENGINEER
T1II Ii XIitti'd011-. k.1111 0 111, 1, INC.'
11001'Ut SNE=t,LENI3riRGER & E! SSOC_
i FI,U12M I`INA Irk
41-8G_3 VY)ARDWALK, SUITF 212
RAN(: III NIIRA�;111 OA 82270
PAL&I DE'SIMI' CA 92211
(76M777-7766 l "t4L 195.14
USE OF PERMIT
sI -,1:1
tiL l) Lf Jf G I'LAN SMllt
TRACT CONS' M1JC !'1k)iv .', it3i1.0i► .3F
14)RCIVI'A'no 1( Liri1 3F
0ARA(;H/ rVti'r'yWY 444.(H) SF
i!;5'i1MA TIEfl 04ST OF CONSURULMON
141.248.40
PERM 111' FKK SUNIMARN'
CONS"rRIJC710N FW- 101-000-418-000 S?86-50
PLAN 01K,(7 MEE' 1f)1-tN.jO-•139-318 S&t7.?1
NfUCIIANICAL Flit: 101-M-421-000 $60.00
li1.ECI'RICAL 1 Fri 101-00"20-000 s141,48
PLUNIBINQ FEU'. 101-000-419-000 5140.75
S'm>,K3 MCYt'1()I4 In.. - Resin 101-W-141.0 N) S14 12
OtAIANG FEE 101-000-X123.000 S2o.w
lNMA;ri-ItUC" IRE F81i 225.000-X144.342 53.130.21
ART IN PiJE LIC 1'I.ACES RlIS11? 701-000-; 55.000 3103.12
PLAN r'HV'f: FIX 1101-001.? 0)-318 -3485,93
Pi v�I E 1-CfrAL CONS1kr K-1'1ON AND PIAN CHECK
$5,044.00
LESS PRE -PAID FEES
4485.93 ;.
J U L 2 9 1997
rout Pxmmn, r• 1w:m otic Now
S4,558,16
107`t` O.,_
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
O.K to Wrap Q
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 / 9
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 PI . Test
Final
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
IP
Gas Test .�
Appliances
Final
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)
COMMENTS: