9706-102 (PLBG)U)
F-
N U"
W
O0 C')
I�0Lr)
W
O�
(D 1- O)
ca
F- d
Z
(Y)
L0
N
ON
U °)
2 Q
C:) 2 Z
r F -O
XW�
mUU
O
aU-)H
Z_
cb ::)
�O
Q
J
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
00961 C Ali i` ,.' 1031;97
VDate`� Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thatCI 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
performance of the work for which this permit is issued.
) 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.
ST.K I'E FUND
1111, 1Ilk ly-96
(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
subj ct to the workers' compensation provision's of Section 3700 of the Labor
Co e, I shall forthwith comply with those_ Fo visions.
P Y �t
q te: �S 7 4pplicant-
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
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 authorize epresentatives of this City to enter upon
the
above-mentioned property for i ; sp c ion purposes.
fgnature (Owner/Agent) Dated Y�
BUILDING PERMIT
PERMIT#
CONTRO L#
v,a
5366DATE
6112197 VALUATION } LOT
: TRACT
JOB SITE
ADDRESS . 54-70i A NWA CH{iNLA
774.27441V
OWNER
CONTRACTOR / DESIGNER / ENGINEER
INTR IAMB COYLE*
L, CONO SEWER SERVICE,
54-705 AV1 NiL7ACiUMANZA
E;.fr. I305Z 192
LA QUN T A CA 92253
'PALM DIRS : K1' C.A.
92261
CBL#
342
USE OF PERMIT
lti[,1.ji�3_F�
+da01 r10. P A&10tiNT
I,50t+.(Ii3 is
ESTIMATE,]") COST
OF CONSTRUCTION
:I1500.00
ft".L+:BiSt"ft(`I� 1!'1r�; S'f.tlVl((r3r11:r1t9k�
0,(,JN1HTt4(I• FFR ._ 9171WER 1.01-(W-419-000 $30.00
FIA D X11. GUNSl UC 1tt)N
:
�W
1 SS -P P:Aff I) FEES
o
JUN 12 1997 T0TA1,.PF.,RfA4T FEEtS OVIC'NOW
1100.00
CITY T OF Q� ldIl�VTA a
'RECEIPT
DATE
B1''
DATE FINALED
INSPECTOR
.fl
INSPECTION RECORD
OPERATION
DATE
I 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
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
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
Encapsulation
Gas Piping
Gas Test
Appliances.
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough.Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)