9802-056 (SATT)H
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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.
License # Lic. Class Exp. Date
Date y',�"�Signature of Contractor- I
OWNER -BUILDER DECLARATION
I hereby affirm under penaltyof perjury that l 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:
Cartier Policy No.
'A E 111[dD 137101597
(This section need not be completed if the pennit 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 be me
subject to The workers' compensation prows)s of Se ion 3700' of the abor
Coded shf fo�thwjth complywith those prow Ions. "
Date: r Applicant
i
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)representatives of this City to enter upon
t e above-mentioned property for i pectiori�purpo es.
Signature (Owner/Agent)- Date
BUILDING PERMIT PERMITN CONTROLM
!D,119:x i)�w►
DATE VALUATION gj � �?�LOT TRACT
6827
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46-16
C, 1 6
JOB SITE
ADDRESS �,R:j t E�.ril g ti 1J1t{�� AL
APN 1►�-.1}••1711 A
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C.v ,+,�n....U�� 1 tw i C:l../1 all....
. , . a •.,.f_. ..,e w aa.t+ l d
k'.1.,}, E"'OK 1716
79293 RANCHO t.,A QiANITA DR -
LA QUINT A (,A u2'1153
LA (ji.)lNTA CA
J7(% )?'dl�)41 la'l1..# 20%..
USE OF PERMIT
,),�i1'i a �, r�'ri;t ► r� 1�1:,.��1 n, ijLf�td r^fitc;li i�ItYTCitd u`i� Er.:is.itli��i'i,Ei7 .
V.y',o VoR M IAT NILE IS:31)ANCE'" OF SANIE PLAN TY,V%,
A
R 0 8 1998
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PCIK.l:,ilJl ATIO t 50.Ur) SP,
UARASjWCARPOR I' ter.-,►�: S CITE
FLA QUANTA
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T'1111i ATIVIM COST OF
L'S0
if "PI RPA YFb11Flit; SUAIM tiRV
-
C•t1'NS't?_1IJC1'I()N FFL 101-01}i?,41X-000 $867.[x:,
PLA -N F113 101 ti}00-41, 9. 71.1.13 $? 7934
14i1�C1.1ANlCA1< t 13i 10 1.-0110-42 1 44.X)
fX, V-F2.ICAL FEE. 1()1-0 1-420-000 a1 X5 9;3
?Lt).NiBfNG FEE i () i -(K9)_4 L'? -U00 $ 1355 25
fS•1'1 0NO NIlOTYIN Fr3;-.RE;>f[> 101440:'41-000 gi& st.r
G -RAIDING F)-,- 101-000-427,1,AM)
11\F1?RAiTI1U I`URE Ft,1 225-000 4-,13-:3,J2 &V166.'r'S
ART IN .PU81.lCYLACES - lt.i>S1[.: '7()1-t}I)t)-255.(i0U '),)62.4x?
SUB-I'MALC*Q-1V,'TRr CIF0 rAli"►PJAl+}1')111-i;'st:
170TA.1, PERAJI If FVES MAK NONV
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
NSPECTMM RECORD
OPERATION
DATE
INSPECTOR,
OPERATION
DATE
INSPECTOR
SUiLDING APPROVALS
MECHAMCAL APPROVALS
Set Backs . '?'V ACly
Underground Ducts
Forms & Footings •2 41:�V_
Ducts
Slab Grade L
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans _
O.K. to Wrap e 7 `Z 0
F.A.U.
Framing - ed -g
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
Farts & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath - `(i
Drywall - Int. Lath
Final
Final
BL®C Kd ALL APPROVALS S
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLU MNG APPROVALS
Gas Test
Electric Final
_
Waste Lines ,S % -
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Q.K. for Finish Plaster
Sewer Lateral
Sewer Connectiong
Pool Cover
Encapsulation
Gas Piping
Gas Test G 13-9
Appliances
Final
Final 72---
Utility
-Utility Notice (Gas) Z
ELECT AL APPROVALS
S
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
utility vouce (Perm) _112 -2 7 E �