9706-029 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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
c� W Professionals Code, and my License is in full force and effect.
p Z License # Lic. Class f. Exp. Date
r. LIJ 488234 $ {� 12131/'97
Ir
C6 ZO N ate s ignature of Contractor
co U °) OWNER -BUILDER DECLARATION ./
Hd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
Z WORKER'S COMPENSATION DECLARATION
C) :2Z I hereby affirm under penalty of perjury one of the following declarations:
Lo <FZ 0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �L compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q U (Y,) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
I'd- Z Carrier Policy No.
°�° O YrA' E FLM 67635596
J
(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
3 ko
'bject to the workers' compensationrprovisions�of Section 3700 of the Labor
de, I shall forthwith comply with those provisions.
ate:' x• `-1 `-Applicant
Warning: Failure to secure Workers' Compensatio.vi 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. e
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 application 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
co `struction, and hereby authorize representatives of this City to enter upon
t e above-mentioned property,for inspectiort purposes.
/Signature (Owner/Agent) `-,'i j' - L_k Dated` 1 �1
BUILDING PERMIT PERMIT# CONTROL#
� '� 8,i
DATE VALUATION 33^04." ��" LOT 17 TRACT 5.�
�f
qt
JOB SITE
ADDRESS •% ?4AMS S DVIVEi
APN �
OWNER
CONTRACTOR / DESIGNER / ENGINEER
THE EXCHA.NCE GROUP, INC
ROGER SNELLI NBERWER & AS&)C,.
1 PL DRENTINA Ulf
4I-%510ARAWAM SUITE 212
RANT HO M11 AOF c'A 42270
PALM DESERT CA 9221.1
(760)777-7x5 CBLO 1858
USE OF PERMIT
FD
WO WT 17 PLAN 48K
TRAK'T C0NS•1RtJc'Tt0N 2,2W,00 SF
t11_*C PATtu 110.00 B
0ARA_W1("ARJK)KT 471.00 8F
nTiMA'1'IKD COST Of CON3'I'RUCTM
1,#1„ 154.."
I'1j:KPAI3'>1 CKINi.1MMAltIt
(70NSTT121H-'1'1Ft-M FEE 101-piifi-418-ODO 6749,00
P1: AN ("I*X'K Fff-, lot •<IW4W-318 361874
ML-1-11AMCAL FM 101-4110-421-000 $60.00
Iiaik' 1LICAL F h 1014)"20-t'!w 1114.92
Pt lwLW) FW1 1€114X*4110-EfflO 3140.75
;°1'1"oW1 Mgt's' W)N FW. - R 310 101- X)0-741 -W 31 -m-
MA,tAW's R1 101-000-4.23-4059 $20.00
1hi1r►Ul+`i'rR0('111Rh FEE 225 -OW -443-342 x2.1111vs.5A
ART 1N InML1C PLA(TH - RKMIi: 7014XV-258-(fOti s7l.v
P1. AN 01P(.V. Fid 101-01KI-410-318 -S464.06
PIAWI QwTIDTAL
CONKMIX"MN AND PIAN CHECK
S4,706.:t8
LESS PRF -PAID FEES
4461.06
J U L 2 9 1997
TOTAL PZRMIT ".FA DUE NOW
$4,,742.32
CA
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs P
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 —
Appliances
Final
Final
Utility Notice (Gas) j1 -L ,
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 zk 4c
Utility Notice (Perm)
COMMENTS: