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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
65396i 14 i/98
' r r 7
'bate l VSignature of Contractor A r
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.
Yct) I have and will maintain workers' compensation insurance, as required by
S ion 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 5 Policy No.
N".1 'hr'i`I:, dy ° LfM) 1423671
(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 my manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensat! provisions of Section 3700 of the Labor
ode, I.shall'forthwith comply with h se provisiohs; {C "
Date: f \.``.� Applicant `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
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 histv
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 P I
correct. I agree to comply,,with all City, and State laws relating to the building. -r”
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyfor inspection purposes.
ignature (Owner/Agent) +°t! ! �tZ = Date
BUILDINGPERMIT PERMIT�fNrS CONTROLk
DATE VALUATION S:jii3, ,�j 7.� LOT39 TRACT 17 K&
s v
ADDRESS
%alarU /t tiA9
r
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C;1A1'.VINT fi;OMES ; :C:
TMA 1.1 CONS"1 ;RUCi117,N
51.370,WE'N10A BERMUDAS
6i COir►a1'.€ y cluo DK S'1•.6 m-•2
LA. C,)11IKI.-A CSA I x2253
t?ALM.1?YSE 17 CA. 92260
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(70)360.8453 Cil 0f 496S
t
USE OF PERMIT
SF'll
LOT 39, PLAN 213 ('('M"). SFD-'I)M.t Yi' DMV -140T INOXWE
RLOC K WALLS (.)fr2 POOL, PLAN CIi C.A: Pd. RTION OF rCE'5 i(#:�Uf,7e ..0 75%
1°C1R MIR.` 'I.K.-P, ISSUANCE
CUSTOM C'014%'17RUa'"T1ON 41.580.00 SF
1'O.)LCh'ATl'O 800.00 S
3ARA_CiMAltPO t' 811.00ISSF
EST fNLATCD) CDST OF C:'ONS-.f'RUQ:."D 10N
133,.317.1611
PFIRMIT HMI.4iifwMARY
CO Nti'1RUC1110N F wl~: 101-W- 41 9-0 ) $1.(031 50
del,,}iT)C.KKX FITh', 101.4)00.419-3 8 $13249
lYR7:.1rA.EfYI Vl.ON.+.1.'Ld:: 1e1-000-321"000 .D.d A.50
.
L, !»Ei:, fFUC A1.1 L k 101 -W0 -4Z0-04)0 5275.5:2
I)t„C>N1)3.€tuf(:f I 1 i; 1.0.1-000-4119-0,00 $2�12.iiu
+'I`i;tj►iiC,1 A+Cd 1'tyf.1't.1 117 i'_r _ ?'tJ?ill l) 10 14.K10.•24 i ^(AX
1PH-
INTI I}13
�.if.Ettr).saVt.i t 3}v
iii` to>8114ifi.1'GtteFfi_wi 2B-000-44-1-11:2 $6,00U.00
A10' t 1' 1, 1",R0,013.3 - i-ti;SR' 701-000-2255-000 •� y S7f1$; !q
pp -4 ,1t1_TC T AL t:f)_iVK)"la(J(;"VION A.NT) PLAN Cf 1!°:t';lt
$9,3RA 63
LESS PRE ft
$().Of)
-PAID EMS
JUL 15 1998'i!'cD l�9, >� �a�3 .� I�'>Z�r� 1)t7f NdDia!
S9,3:90.63
R1 CEIPT.
DATE 0BY
DATE FINALED X
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
(< <(
Ducts
Slab Grade
Q/ Zi - rfi /LUG
Return Air
Steel
Combustion Air
Roof Deck/(_�
S = CIO
Exhaust Fans
O.K to Wrap
Framing
II G
�� y c�,�—
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall- Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
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
COMMENTS:
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
i
i
Final
Utility Notice (Perm)