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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
vDate 7%.��' Signature of Contractor
OWNER -BUILDER DECLARATION'
I hereby affirm under penalty of perjury.that I -am exempYfromrrrrthe 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.
(%e) 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.
(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�ection 3700 of the Labor
Code, I shalt forthwith comply with those provisions,
v/Date: 7// G/,"q j Applicant
Warning: Failure to secure Workers' Compensa(tio'r coverage is unlawful and
shall subject an employer to criminal penalties andcivil 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. i.
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:,.-
the•above-mentioned property for inspection'purposes ^c.
/Signature ,(Owner/Agent) ��' � '' Date ,
BUILDINGPERMIT PERMIT# CONTROL#
DATE 4 VALUATION LOT `� # TRACT
IQf15
$217.864,40 ?11
JOB SITE I
APN
ADDRESS sft.,u i.Qa)mt cuvs-'r
761,.4;I0••62.5'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1 %f:
%11'NI'; WFF "l' I#0U.I..;;N t 11 W:
730 I3 SV L,;B.'F 3140
`I` i•fIGliWIkv I I I
SAN MEG() CA 92101.
1:,A QUtlTA Q'A 922E;3
USE OF PERMIT
:vigil i
of u - vii I., 1.o–, ::t. Irkr i X" . _0i:',f MIT DOES int il' INCLULYE RC,�CK
W X L-13 Olt POOL. V! AN CHECK i`1 f.3 C 13DUCED AY 75°fi 4�C7Ft 1Vli its '�'i!'i.13
Cl3S"t ON4 C ON .l'1*tUQ 1'T*`JN 2,572.434) &r
432.0 S1F.
G9ARA(,3H1C'ARVCll 1' 600.0 SE`
/
1`iS UNIe" II'Al' ,.T OF
PERMIT FEE SUMMARY
CcaNSTIR0i;;TION1ZHIll 101-000-4.18-000
IMAN E:KElfX FEE J 01-000•-439-33 [8 52::15.19
XT(JIANICAL FW 10.1-000-.421-000 598.50
EI.13CrRVCAL 14',11' 101-000-420-000 5I.59.52
�TvNvtwo Fa 1014100-419-000 $138.00
�:`t7?f).tdct t�EC)Tic�1N!�!�I;..1Z;r�rr �0d-01X?-4i-Q3f� $w2,'��
'C17:Lrii3l t; %1,L' 10:1-f -0*42,3-000 $20.00
1NFRAS'I'.kUC.°I'iJk8 F3.tr '225-00-443-342 S;4,772.67
ART FN FIU13LIC PLACE 8 - RE.P`11) 701-000-255-000 5214.66
SI3 3i -TOTAL CON SM UCT[ON AN. D PLA NC1.W5C K
$6"313,03
. JUL 141998 LESS TRE -RAW FSES
$0,00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
—t(. -
Exhaust Fans
O.K. to Wrap
/0 77777—
F.A.U.
Framing
Compressor
Insulation
— Q
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath—
Drywall - Int. Lath
Final %�
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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
Sewer Connection
_
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.I.
Smoke Detectors
Temp. Use of Power
c
Final -
Utility Notice (Perm) 3
COMMENTS: