9811-067 (BLCK)LICENSED CONTRACTOR DECLARATION
0 I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
WLO el
5.37333 A B 8/31/00
r—
oZ ate s- t'> ignature of Contract �-
coO'
J U C3 OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
to 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).
( ) I am exempt under Section , B&P.G. for this reason
LO
N Date Signature of Owner
ON
0)
d Q WORKER'S COMPENSATION DECLARATION
C) 2Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to Self -insure for workers'.
X WyLL compensation, as provided for by Section 3700 of the Labor Code, for the
O �. Q performance of the work for which this permit is issued.
C3 Q L)( ) I have and will maintain workers' compensation insurance, as required by
O C) Q Sextion 3700 of the Labor Code, for the performance of the work for which this
10: rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
0 O STNI17. RiNPJ t 110312:1-93
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
sub to the workers' compensation provisiops of Section 3700 of the Labor
3 C9de, I shall forthwith comply with•those provisions.
ate: Ill r-12 ApplicanYi- - ---
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
4 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 er6plo4yeed`
2. Any permit issued as a result of this application becomes null and; Vold 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
the4bove-mentioned property for inspection purposes. j
VSignature (Owner/Agen)"-k---•r"'.--,'__�- Date I I
BUILDING PERMIT
PERMIT #
9811.067
DATE 1111,0198 VALUATION �(# LOT
TRACT
'JOB SITE ADDRESS 5d-^1" .c'IAV�l:[� WDA CA1tRANZ
TAPN
_ -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I\?IC
mf miltt.,,SIC.
P-01 BOX 1555
P-0'* Y30X 1535
LA t�C [NrA CA 9253
LA. Q(5.[N f'A CA
92253
(760)340--2726 CI
Lif 2.526
USE OF PERMIT
il:l�lF.dcAi, BUILDING
50 L,F.. 5' RETAINIiNG WALL, CLIN S`i'AND&RD
5 t-'1'. WALL
50.00UP
Wn, LVAK SD COST
OF C`C INIXTRU TLON'
:1,0.2.50
PI"M IT 'FES; SUMMARY
CON'Kf RIX 1' ON FEE' 01-000418-000
€F
L
Ct,IB fi(-I AI C i�, NS-TRUC:°T.iC)`N
AN17 kA.N C,�[EC:�.
$27.0
LESS PRE-INUD TICE-:
$0.00
1998 TUVA.L VCKNUT FE'R.S 00i NOW
$27M)
Nov 1
a�a
REG'E11 T
DATE
BY r
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
OX 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
POOLS - SPAS
BLOCKWALL APPROVALS.
steel
Set Backs
Electric Bond
Footings
Main Drain
Bopd Beam /G
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
t
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)