9804-177 (SFD)fid
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
i
74.'IRe7=Z Z / 1213 199
Date f� r'� Signature of Contras J
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
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.
V 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 I Policy No.
STPI:L'1; FUND 1421452
(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 mannerfso 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
,Code, I shall forthwith comply with th se provisions: % /
Date: �ZZ//'Wo Applicant - fir.�G��
Warning: Failure to secure Workers' Compensation coverage (aninlawful 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 authori a representatives of this City to enter upon
the above-mentioned property.,oriinspecctiioon` puurpposesoe
,.
r/
Signature (Owner/Agent) `Q�,
t . BUILDING PERMIT PERMIT# CONTROL#
DATE VALUATION LOT 91384.177 TRACT
-� 9e 6�,5
6 • /o S88,338.2s 11
JOB SITE
APN
ADDRESS
32-2-05 AVENIDA CARRANZA
773-212-5-0211
OW[VE.�
CONTRACTOR / DESIGNER / ENGINEER
WORLD DEVELOPMENT, INC
WORLD DEVELOPMENT, INC
PO BOX 1.3287
PO BOX 13287
PALM DESERT CA 92255
PALMI DESERT CA 92255
(7+;10)77'2-1919 CBLft 3028
USE OF PERMIT
SM' - .PMMiIT DOES NOT TNCLUDE BLOCK WM LS OR PO4
PAID
Jum
1998
U
'MACT CONSTRUCTION 1,375.06 SF
POTtMPAT.IO 173.00 SF
GARAGElCARPORT 156.00 SF "ITY ®F
S a
� d� 9 °
BLOCK WALL. (11T11X) 311.25
d FT. WOOL) F'L'NCF: .00.001
ES tI1V1!ATED COST OF CONSTRUCTION
N8,338.25
PERMIT FEE SUNt1 AWA
CONSTRUCTION FER 101-000-418-000 �S�1tt.00
LAN CHECK [E 101-000-439318 3500'9
NJECWu'NICAL FEE 101-000-421-000
R -LEC: RICA1. FkE 101.-000.420-000 8124>33
PLUNIBMIG FEE101-000-1L 9-000 S l,dt;.50
STRO]gG MOTION FEE - RESW 101-000-241-000 X3.83
GRALUNG FEE 101-000423-000 saO.Oti
INFRASTRUCTURE FEE 225-000-U3-34.2 11.885.41
PRECISE .PLAN 10.1-000-4.11-3,15 $25.00
F'.rvR DETAOSI T 1.01-000-439-318 4250.00
SUB-'1'CjtAr.. CONnRUCTION AND PLAN CHECK
LESS PRE -PAID FOES
- $21N 0 0
TOTAL PERMIT 1<'+'` IIS DUE NOW
53,1.12.28
1.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
P Roof Deck Exhaust Fans
�,�
O.K. to Wrap �/� F.A.U.
FramingCompressor
��(��
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 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 p0f— Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice - �p
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm)��(�