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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. D�te
1
,Date ; 7! Signature of Contractor
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 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.
5'TAT13 F1.174D 1.31105
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner*so as to become ubject to the
workers' compensation laws of Califorfiia, and\agree that if sho Id become
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'ect to a wO ers' compensation provision$ of Bectu 3700 of�the Labor
e, . 11 fowith comply with those provisions.e: `' Applicant .t
Warning: Failure to secure Workers' Compensation cov age is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City. and State laws relating to the building
construction, and hereby authorize er presentatives of this City to enter upon
Zignature
above-mentioned`pro�erty for pectlon purposes.
�r �r /
(Owner/Agent) I ' D ld �
BUILDINGPERMIT PERMI;# CONTROL#
DATE VALUATION LOT 1}11M. J j TRACT
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JOB SITE
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ADDRESS ,U5 C�.�1]tTA bRi 41E
b4 9-3 86-4ij5
OWNER
CONTRACTOR) DESIGNER ENGINEER
r.:�_ lac s�.l� l' r� :�r l:.a+� �9IaTd'i
!?AMSODINF 1RUC I I0ro
V 0. 13OX 171
'79-295 RANCHO LA QU11flA DR.
I.A QUIN1 A CA 942253
[ A,17U [NTA CA 92"K4
(70,11)77111- G3L(1� 24),Xl
USE OF PERMIT
3F'A - PLAN* A , LC O' 9 55, PE^RNIIT DOE$ i` O,r mcuj7?F ilii cK WALI,
OR PCX�)i.. PLAN CHUCK FEE RF.DUC.`ED '1: o F0R MULTIPLE ISS iANCH OF
SAME PLANTYPE.
CCI>J ON1 CONST1RUICTION 210.13.00 fab'
PO RICH/PA'rit'r I88.00 SI:
QARAQTXAJ?,PQR.'I' 410.01) SF
FST, IMATED COST OF' CONS'.[RIUCT;ION
171,249.341
P1t,RMT1C FEE :abMAIA RY
('t.S tiSTRUC F.fON FE 101 -000 -418 -WO ?rM�1.0
n r-: A.'N CFI) f C..K . EF ? 0J AM -419- f 8 SIM.24
AfE:C11.kNtC'AI. FEE 101-101010-421.O(A) VN.50
J—_(:," 1 X( AL E E 101-000470-000 $1:18.36
P.I.1.!"..)I No P111 E i 01-009-419-000 $ L+31.25
�3Tftt)N0 MOTION FEE . i2f;s10) 101 -00P -2A11-000 a l7 t.n
CIR.AW.NIC 1=1T; 10I-000-423-000
i.1vFRA1,TkUC (YRF? Ftp 2215-00044'3-342
:SRT TN K(ALI.0 Pt.. AC,`F S — KY31C 7014)00•7755-000 $178.32
���=rOT'A1. CU IF4 FRIX T'IO) l y\ND PIAN r. 141."CK
SS zt8S n4
AUG 2 8 1998 LESS PRE -PAID FE
M.00
't'OT'.AL PERMrf VERSI T UEr NOW
""ITY OF LA QUINTA
RECEIPT
DATE
DATE FINALED
INSPECTOR
V. 1i - .. .
NSPIECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULI.DING
APPROVALS
MECHAN6 CAL APPROVALS
Set Backs
Q
Underground Ducts
Forms & Footings
C'
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
7_
Exhaust Fans
0.K to Wrap
12 -Z-7-9e, 4,l
F.A.U.
Framing
Compressor
I- Q -
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
-
Final
P®®LS - BPDs
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLU BENG 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 L _
Utility Notice (Gas)
ELECT=AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Euterior Receptacles
G.F.1.
Smoke Detectors
Temp. Use of Power
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Final
Utility Notice (Perm)