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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
701039 11 199
yy /.
mate //�r%'�:�. SignaturofContractor - >Z
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 pi`operty,. 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.
S'TAT'kz1=OND liiS•'�1A6Ut?i fti
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Qode, I shall forthwith comply withathose provisions.
ate: / /.��, Applicant=,�
Warning: Failure to secure Workers'`Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages.as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on -,his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to entel' upon
the above-mentioned property for inspection
purposes.
Signature (Owner/Agent) 7 t -- `� '"" " y Date
f
BUILDINGPERMIT PERMIT` CONTROL#
DATE VALUATION LOT TRACT , O A 12
•��(ei7t��.YJlCi �K itQ31j
�) i"1
JOB SITEt r "?
APN
ADDRESS S0425 C...i:,DAR LRIGS !
Wf9 i-00-425
OWNER
CONTRACTOR/DESIGNER/ENGINEER
iYa fr rb•.p5rr'7 it.^�`if[:�ii�l� .1.'t�ii7�
LLC
ITUOS A111., 1gOUSS11.4 ieic
7 o.B s STh, _140
78.40I .F HIGRWAY II I
SAN :#;,IHM00 CA 92,101
LA f i1ANTA GA 02253
{7Gt�17fiI-?ate i;RIA 4972
USE OF PERMIT
SRD
NVU -11H t, L(XF 1.8, PLAN kbk.:l;riEftMI'3 OE$ NOT 11 hM_ Ulb)f T3LC.h;�:
WAL" OR POCYL. PLAN r°IiB.,`,.i;: FEI3 M. riUC U) BY 7; fl,16 FOR N1"UlAfIPLE
ISSUANCE. C)I SAN4T3 PLANT' Tq,.
CUS`iONI CONSTRiiC e 17N 2,203.00 SF
,f 103 01114-fA IO 40&00 SF
0AAAGl1C:A1CP0KT 566,00 -S
PSTMi VED C:On OF CONSA'.2'.fs`.`HON
IS&133.70
11.I1,RWI, FEW 4 3MMARV,
CON.VRIJCPON FE33 14i AM -4113-000
Pt -AN Cl1,Cx. rZ4
f6W3C41ANICAL 1-4% 11?I.Ot)i3-f12.I () 560,00
f.f t7 Rft: AL F [iii ! v 6-iiUG��l2fl�i3l ft S,.r4 i
').Cl,Vfr3lt�'S (�i?F 101-01)tD419-00 $166.00
�t'rNnNr� �1(►'i'tr:�'N'1�►� .. fttiagl 1�!1-t1t10-?�1-t>(�lt1 �f8,f1t
fillIW1 I1 Oy f1j1, lUl T1ilI} Iti3 d)00 �'all,IJ(i
i 2215r(}00-443-342 $4;1 Wt 9 t
€lR.'f°!N' +t 1)d.a.(. Izl.RESIL 701-000-255.0.3 $1U10.33
.�JrP1aL�1£itr7C:"TN.ANl�1'I,�l:'IICK.5,s2fI6,22
JUL 14X998
s LA A,
RECEIPT
DATE i
BYE
DATE FINALED
INSPECTOR
yy
F.1 F
G
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
O.K. to Wrap p
F.A.U.
Framing l d —(9 -
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 2
_
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVAL
. POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines .Z - -
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection (- (Y,- T V, �Jzc
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
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.L.
Smoke Detectors
Temp. Use of Power
r
Final.
(Itility Notice (Perm)
COMMENTS: