9706-036 (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 C 1 Signature of Contractor LIt � -'
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
pert rmance of the work for which this permit is issued.
qN 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.
(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„I>,Shall`f_ort�with comply with those provisions.
Date: i I ) ` 1 )Applicant—
Warning:
Applicant Warning: Failure to secure Workers' Compensatio(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 S
application. I
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 tos
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
t e above-mentioned property for inspection purposes. l
Signature (Owner/Agent)-{ t + Date
BUILDING PERMIT PERMIT # CONTROL#
)706-0 5287
DATE VALUATION ,4,4() LOT Ill TRACT 18-151 1
JOB SITE
APN
ADDRESS 7X-715NMILKS D>KIW
60W11/4II-113
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1111: 17XIC1/1MG1: 0111,01AI,'A41C
ROG)its-Sr1.111,.�01B;iRGE ft t,, A SSOCI
1, r'l.r laity"t'i[4A 1A
41.8651BOAkOW.atL,k, SU.rfF 2.12
ItAW-310 MIRAGE CA X7270
PALM I'tf?:rM17 CA 02211
(7601777-7766 t'.IiI 1958
USE OF PERMIT
'rRAC r CCrN!SrI1 UCT10N 2,x(h1.4i0 STi
L"Cl�tf'FUNA'1')Ct 1 li)1)E) Sfr
L"*ARAt"tl•YC Alt1x>>lti' 471.(M) SF
4.alx Ll`i4)� • 4wiJ1 (,.1'.71( ® (.�ll\�7•i
f'EWMi:E` VkGi S111Vt1♦iARY
rONSTN' iCTION,FIX 101ACK?-418-000 $748.00
PLAN r19.:r'K. 913 101 -WO -1-19-318 $618.74
h1CC11At,TlCA1..F CI•r 101-000-421-000 S60.91)
PLL rRICAL 111-h 101 -000 -1420 -CO $I".M.y2
P1.CI1b1kiINQ F13, 101-000-419-000 Sf4f),73
,T!'ONG M_01'10N FFE - R11FSJD 101-000-241-000 $13 tj
C, tAIANG M 101-M-423.000 $11,60.60
1 14111t Af>T RU C 11JkL-' CLfw 2-2.-c- lti 443.342 3*11 +5.36
AIT IN PUBLIC PLACES - $1F.q11) 701 -000 -255 -OW $75.19
IILM14 C-10:CK CFE 101-0M-�'139r318
r
r.,
j';pil0-'1`QTALC0N,,TrRUC71C.)+! AND Pi,. i r:ilf:CK.
$4,706.38
LIESS NU -:PAR) FEES
446-1.06 ;.
J U L 2 9 1997
TOT Al. PC;'RIMIT FP,9'i 1JN'11~;NOW
$4y2423Z
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ECEIPT
DATE
By 7
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APP OVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 4.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D II - Int. Lath
Final
Final -
BLOCKWALL AP ROVALS
steel
POOLS - SPAS
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
Gas Test y _ y
Appliances
Final
Final
Utility Notice (Gas)le Lc Z -j
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) 02
COMMENTS:
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