9808-148 (SATT)LICENSED CONTRACTOR DECLARATION
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
(V W Professionals Code, and my Licenseis in full force and effect.
:3 Cn License # Lic. Class .ti Exp. Date
r-- CY 1l')
Z r vbateo Signature of Contractor
p
0
U OWNER -BUILDER DECLARATIOi!
WF— LU ~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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):
C'') () I am exempt under Section , B&P.C. for this reason
U1
O N Date Signature of Owner
L)
Q WORKER'S COMPENSATION DECLARATION
� 1 hereby affirm under penalty of perjury one of the following declarations:
HO O 1 have and will maintain a certificate of consent to self -insure for workers'
K LIJ u- compensation, as provided for by Section 3700 of the Labor Code, for the
nJ Q performance of the work for which this permit is issued.
U 1 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
i 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
cb 5
r` C) ST TE Y UINT) 0711794
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 agrqe-thet,ifl should become
3 subject theEo�
rkers' compensation provisions or Section 3 0 of the Labor
decl h�'11 fith comply with thoseL rovisions.ate: ; '�' Applicant �r 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
r 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 3,
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 Ouinta, 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 authorizepepreIsentatives of this City to ente upon
tLthe'above mentioneb prope�rty�for in ectlorrpurposes.
4gnature (Owner/Agent)_ �L` —.Date r � /
BUILDINGPERMIT PERMIT# CONTROL#
StYll !7i .I
DATE VALUATION LOT TRACT 25
JOB SITE
APN
ADDRESS 4.8455 C:tk,4ii'd A I)RIVE
O ER
CONTRACTOR / DESIGNER'/ ENGINEER
.1. D. i�► car sZ+ r�t:VE, OP11':P:'''
��. �.. a �..�, .a. w'
St"A K. t✓t=L°�'Sf'�'.l:' ;flt'rH
1'.0, 130% 1_1i6
7�1-295 RANCHO L.A. QUlty!'!A GIS..
i. AX t�(JnvlA ti's\ 92253
1,A 0L flflA CIA, 97751
USE OF PERMIT
�1RIGi,t t-AWl.i'A't �'A c FiN.l7
>,i'A PLAN A, LOf aj SrS. PERMil' i;OES NOT rACLUDE BLiaC u7tii.1.
OR P vOL. PLAN CH-EAZ' . I4 -h .REDUChX) 7S"lo FOR MUi..`I'l PLP, OF
SAM1E PL,AN'l'YPK
C�I�STi,�til I�:3i�t;'Tl'iLTC'1'I��id I.47sAti Si
1�OttC;FL'l'A'I CCi 150.00 SF
OAR.AGEiC 1.R.PCAi;,T 465.00 SF
Mf�.)•A•�Iv'i.rY.�4•.�+..� cV.!1•t cilli ♦.ONST�ia.14..1' ONN
J64,wi'.-.5e
PERMIT FEE SIRMJrr'SARY
C-7ONSTRUCTION FEL 101-000-418-( t _%S,6700
PI.,Vac~r(t ca FFF I1D)-!100-09.•318
[WIXIIA IC AL FEE 101-000-421-000 $105,00
ELECTRICAL Ffil. 1!31-(}0Ci-X213-000 $135.93
PLUMBINQ Fi~F; 101-1100-419-000 $155:25
_01-40 NtOTI<)N FEF - RE -510 10! -(M-241-000 1116 30
GRAVING FEE 101-000423-000 $20.00
llvf'i' MTRUC,TUIRE SEE 225-000-443-312 $3.cd)6.'15
ART ltd PUBLIC; PLACES - RESIB-701-000-25:+-000 9iS'b.tU
1AI C�C_)W'%7R X`110N AND PLAN CHR -W
$5.�08.57
P LESS PRF -PAID FEES
$0.00
AUG 2 8 1999 TOTAL, PERM OT FEF—i 1)4Ti~rNOW
ITY OF LA QUINTA <
RECEIPT ,.
DATE f.
J 12 /
BY
DATE FINALED
INSPECTOR
O SPEC TM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLDING
APPROVALS
MEQ:HAMCAL, APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—Q
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
r
Drywall - Int. Lath
Final -
Final - 'Sl�
SL®CKWAL.L, APPROVALS
POO LS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUhil MMIS 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
/(f
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
EILECTMICALL 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 Notico (Perm)