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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
i•1_�25 Ii 11/30:�1�j
kDate 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.
(X) 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.
STXI'1: FUND t440125.98
(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
Cede, I shall forthwith comply with those provisions.
ate: f 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 enter upon
the above-mentioned property for inspection purposes.
VSignature (Owner/Agent) < Date
BUILDING PERMIT PERMI91111
01 r
DATE VALUATION ti.i } R 3 LOT }; t 1 1 TRACTJOB
SIT9
ADDRESS 79-167 Clu1 RINO
APN 769 670-406
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I'I i;t!;; i)1i�'1:I�f:1'Rili": T LI.C'
* 1 ".P V1P1 11(,1.F5
M370 A ENIDA 1EIGWDAS iil: I
I8-04 (-ALLE E&FAlk), 2NE-t FLOull
l.r\ (,lUtN i'A ('A 02253
LA QIJINTA (.'A 9224,4
!7(%1)771 -,Soo !'lit.# 5.107
USE OF PERMIT
"INLiLf-, FAMIL11 t_fWE:LLINt-i
Vt,AN I 15 - St, IJ - IIkac MIT OVi N NV E INL LtiDh kiwi—h WALL;1 VR
1•(x/1. NI. AN C3IE CK FEE Rls1.1 AAA TY1 )R M1. 1;1 ll'LI, IS30AN(A; cif•
SANIEi KAN TYPE: �
NOV 0 5 1998
i`.11:iTOINI 101401 RUCTION 3,77 100 S
PURL EtlPAflu 774.W SE--
CiARAO&CARt"ORT 727INt :SE
.ESTINIATEM r1EST OF CONSTRUC11 ON
13, 304.30
PE:RNOT VEX, SUMMARY
(X)NS'i'R).}(:r10N FIA- 101-"-41ll-0130 SfAkhh 00
111 ANr11 rk 1, FF 101-000.411-1IR t�q7 tr)
1111:CIIMICAL [7E.I✓ 101 00t} 121 00135141 IX)
I'sLE (:J'RIt:AL FEiC lilt -(1W 120-iiQO S241s 0
111.11;+,WI N O FEF 101 -000 -419 -Wo S'»! /.5�►
9TR0NGN401*1nN Ia�H.. Rhsrt iQ1-(Kx)_�41-+ltlti x�t >4�
GIL��I)I2.G FI1s 101 ()00- ID -000 $20 W
INI•ICAZNIR (.'tIIRhPLE 225-GOt"4.V342 if>,O)4A?
ART IN PITHLIC' PLACTS-1tESIV 701 -OW -251.0X) $us 76
SiIll-"yVAI,t't)N,1T%1fcTION ANTI PI AN(1114W
tai9611t
LESS PEI, PAID IES
cr) (it)
1170 CAI, PERMIT k'b;1s.S DUES; NOW
SM.WP7.48
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 o1
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing _ - C
Compressor -
Insulationg
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
-Yet-
Exterior Lath - /.5-
eDrywall
Drywall- Int. Lath L
Final
Final - -
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste LinesHeater
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
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
Final
U(ility Notice (Perm)
COMMENTS:
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