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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.
lCk—
Lic. Class Exp. Date
131196 �� �� 6/3(4`37
Signature of Contracto
v OWNER -BUILDER D&LARATION
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. fpr this reason
Date ' !7!nnt� 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
S ctio 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.
►'f1117:F0141) XA$,
(This section need not be completed if the permit valuation is 00.00 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
Coq , I shall forthwith comply withose provisions.
Applicant
Warning: ilure to secure Wor ers' 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
conss"ction, and hereby authorize representatives of this City to enter upon
the, bove-mentioned properly for inspection pur pses.
nature
Date
BUILDINGPERMIT
PERMIT#
CONTROL#
+moi+
3928
DATE 414196 VALUATION , �.� LOT
TRACT
JOB SITE
APN
ADDRESS .-391) AVENIDA �.1��'HANVA
774.0814),Z6
OWNER
CONTRACTOR/DESIGNER/ENGINEER
t,'. IC I (AE1, 51(._*'TN ELI.)
1.A11.0 PA1,ACIO
:,.WO A�TNtDA CARR-ANlA
54180 AVE. V LASC
O
LA Ca11iNTA CA 01253
1.,A Q INi A
, CA 92253
(619)564-3541
CRY..# 3021
USE OF PERMIT
AJf! aisAA1. kWILMNt.r
7'1:AR t:>1+V EXISTING 1 ROOF,
948411 -VT V KINTING .Sf EFTIN(I ANY)
INSTAt,f. i*1,A_g9 "A" 4111401 i -s `1't�
Vf4i UX.1 ON
3"IR0.00 1.31
W,. 111! MA'FF,' 0 ( UST
11' F C ONSYTRt1i:"1'K 1fN
PERMIT FEK SUlliMk+ 141
1tt;W1� *F I:P:ds" tol-C(?()-1118-000 $l£t.iftl
( A ;�1A1 f YrA . '; NWRA JC:VION
AND 1 Ul N C:EiLDL
XYD ix)
,D
1, ESS Pk -PAIL VIaK8
SEP 04 1996 1 OTAL 1-11111s UHT
ITEV D'Iffl; NOW
i
i B_y
- -- -
RECEIPT
DATE
B •A- / j
DATE FINALED
INSPECTOR
4V
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
OPERATION
DATE
1. INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Set Backs
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
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROV LS
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
j
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Finale/��
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles E
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice