9810-178 (SFD)LICENSED CONTRACTOR DECLARATION
I I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
W
o ZO
/Dater Signature of Contract or��
CD _
J U C:) OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
M ( ) I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION
C:, 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q I have and will maintain workers' compensation insurance, as required by
O ()Q Section 3700 of the Labor Code, for the performance of the work for which this
LID
li 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierF • Policy No. „.,r
oD = t�V ERICAN ..�rti:a. C;t'�. fi ss rCT'07603CU
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
%Date: i 114,14 jL 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 o
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
thee/above-mentioned property for inspection purposes.
;,lilgnature (Owner/Agent) �� �" �� Date.
BUILDING PERMIT PERMIT # CONTROL#
9810-178
DATE ( VALUATION til.%JI,"440 LOT 39 TRACT 1,O 5 9 0
'�
vv J
n
eft
JOB SITE 179—•595 C��, �.�,iMO
APN !69} 4 /11-1M
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGItN'•EER
fi 1 lv f
l..T.��.
CATE C. i..i.tle`.• RES AIT,
5 PARK PLAZA FrE 400
5 Ft%RK PLAZA, MT,6400
MINE, CA, 42,614
IRVINE CA W16i4
(714)251-6200 MA 5072
USE OF PERMIT
SINOLE FAM -11N MPLUNG
Sr -D. LOT n'3S, PLAN3A, .PBIiUff .1)0 3140T INCLU?I) ' Ilf.00 .K WALT.
OR POOL, PLAN C EXX FFF i'UsiJLi€:.'RO `1311750% FOR WLTIPLE ` ,33iIANCE
OF SAXIE.Pt,AN' YPH.
CI3S; OIN-1CONSTIZUCTION '.2%557.003F
VORCHWATIO 169.00 St-
0ARAQUCARNC:3.RT 534,00 S*
ES,11M TED C031r OF (MINISTI:.UCM90IN
411,904.40
PERMIT FRE Si1J'MIMARY
0ONS'I?WCTION1?'1•E 101-000.41X-000 St,t►af.St)
r - Fr.
Tli1~CUANICAL ria 10.i-AtlO •1'l1 110(3 S>�.
FUlCTIOCA'L..FM W7.68
KAW1111NQ FEE 101-000-419-000 SIFi1.25
q'FRt7V'N 31 i.�1{i'.CTC.I,'N F lIiF - 7{ESPI• 10141!1i1-24 *14X00 V 11. 19
GRAI.`.►1140 FU L ]WI -0001423-000 $20.00
iNFR,AS'TKUC".a"IJ.R FEE 225"443-341, X1,717.':5
ARTIN PUBLIC" PLjkCES - RE AU 701-000-25:5-0010
'1
A.. CONISTKUC'T'1ON ANDPLAN (yK17(='.K
$6,690 7'a
1' LESS 2'.R -PAJD F.E'E`>
V
IS0,00
NOV O 9 1998
'f0`.E:Y t1.,.1%1R1!'f AT i(KEN 1)i1R. N W
RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
INt
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs —/ -
Underground Ducts
Forms & Footings ( (
Ducts
Slab Grade 22
Return Air
Steel
Combustion Air
Roof Deck . 2
Exhaust Fans
O.K. to Wrap , Z
F.A.U.
Framing (
Compressor
_
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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 Lines — Q
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—
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
{
Final — Gj—•-
Utility Notice (Perm)
COMMENTS: