9811-012 (SFD)x w
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
/,. 74302.E II 1 .1.1/3009
Pate A- - Signature of Contractor `
/ SI/'..
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.
( ) 1 have and will maintain workers' compensation insurance, as required by
Se6tion 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.
.STA'.1" :[T:IND 1.440125-95
(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.6f Section 3700 of the Labor
Cede, I shall forthwith comply with those/provision's:
,Date: `I- 9,I Applicant {;/f.y t�+%�
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/' -Z spection°purposes.
AV- r a
,Signature (Owner/Agent) _. Dated
BUILDING PERMIT PERMITH
q1; 11-012
DATE lit VALUATION S34. -4,j33." LOT D /12`/ TRACT L!,A 9 2N5
L
JOB SITEi v",[9-3`2 �v �E WINO
ADDRESS /
APN
769-"f"23
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C1.1"RUS DEVELOPMENT LLC.
NIARYIN I Lla`MV8
512M t3.VENID.A BERM.-.- AS SMI,
788-080 CALLV ES"iADO, 2ND FLOOR
Lit. t;rlJWA CA 92153
LA QJINTA CA 92253
(7610)771-1567 CRUH 5407
USE OF PERMIT
Sii.IC;LE FAMILY UV1r'L:1.L1K6
K AN 3.6. 1r,i) - P all+rl:i' OGES 1vt).e :ii�Gx �i3: b:1.uC:tti. tntr�Li,S i31 i}CK,.i..
PI AN C HEC;k i is KEI 4JCEL) 75% FOR fV1U Ti"f LF .ISSUANCE OF SAN46
CUSTON1CONs�MUCTIOIN .1,161,00 Sr
i A�it1C;i ;Aiii�t ►iii' 876,00,,F
Le4d n �ti� � �) CC�� i�.' i � i��F: gt .�i�.i
34014 :�S �
C:;�'tIJ;;"i:t��iFf;:"t'.i:ON h'i!i3 - 113.1-OC3ti-d:kl3-Cl(!(? :'1,51 i.ti0
di, �t�? f'►'�r?C`}C i�..'.s"�} l t1'j i-IlOfl.33;t-�i l f3P�'tfitbf&g.
11,L.trOT(f AL Dirk $217.161
i'i.UNWNcTFHE 101-600-419-000
S-TYAti NK" 0ix$i0 '1f1!-ilf:+C?-�41
L'irvs:€.)ClW FAX 101-000-423-0010
140RrLt3TRUt;`t'iMts PUZ 225-IN10 4'.13•-3422, StD,Ciisu:Gt►
ART04 r-V6LK, :PLAC 8 - ft881C 70IXM,7_55-000 S620.83
k $01—}(.�Fi'T`�i !411, �t_111j'I?O .� P Fef']!V iC- 14.�'.'i4�K
.$'9,06441
::-S.1`1
a LESS PRE -PAID FEES
$0.00
NOV 3 0 1998 TOTAL ,Iۥw RNUT ;FUS t LIE TN)VV
$9.064.41
r
U E
RECEIPT
DATE A BY
DATE FINALED
INSPECTOR
'. r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs % - l /
Underground Ducts
Forms & Footings 7
Ducts
Slab Grade — 2—
Return Air
Steel
Combustion Air
Roof Deck3 /
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 G
Drywall - Int. Lath
Final
Final —
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electrio Bond
Footings
Main Drain
Bond Beam
Approval to Cover .
Equipment Location
Underground Electric .
Underground. Pbg. 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
Pool Cover
Sewer Connection
Encapsulation .
Gas Piping
Gas Test Qom/
Appliances
Final
Final —
Utilitji 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
Final �j-
Utility Notice (Perm)
COMMENTS: