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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
71,4188 0 .8 � 10/31/99
/ate Signature of Contrac of c
OWNER -BUILDER DECLA ATION
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.
(Y) 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.
GC3..LDEN UA L,113 7Na. rtiW"C S IyiGu.S' t10
(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 wo;kers' compensation ovisio� of Section 3700 of the Labor
Code, h�fo7VX, comply�with-t a viso sate%pplicanf-2
/J
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages'as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on has
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant;to`.
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
therabove-mentioned property for i pection purpos s.
/ignature (Owner/Agent) •' F" Date��
BPERMIT# CONTROL#
BUILDING PERMIT yiil�7�2'/9
DATE VALUATION S".909.K{y LOT 14- TRACT 17.13 /� C
/ i V
9 ^ n
_yam
JOB SIT9C� A +Yf p
ADDRESS • -Iss [�►.�ltur ' ��1wiLdL
APN 604-37°'4-014
OWNER
CONTRACTOR / DESIGNER ENGINEER
.
CENTURY CC� ?LLOMD iJ#iiIraS
IE,71i.11ly mVv1'l, r.0vtJK11is ep)
1.35 SO. "D" MWEX' STE. 6200
1535 M 4'200
S.Ai�•.E3EANARDINO C<A. 92408
SAN BURNAFtDINO CA 92WH
(90)391.6.0 07 CBLI# 2.120
USE OF PERMIT
SINGLE FAMILY DWELLING
SFD.Pi. A:N'.)ik.LOT tn,PERMUDOES i,*T INCLUDE BLOCK'�r�i:LS '
OR 1100L. PLAN t;'#iECK HZE RMUCED 13Y 75% #' OR MUL.'.! WIX BSUA N(-_I;�-
Cir' SAMEE PIAN TWE.
"I"RA,,CT COi4STRUCfI0N 1; f iS.00.SE
C�riitF�tri'tA�::A1�:�O�2:`T ti3S.00 SF
CST 116I.s3f.xrf. 0 COS'-' O.T' COLNOTRUC"TIOIN
9019"09 ail
(( `y'•'$� y;r y ��p p p
PLAN CHEF: M 101-000-439-318
CCaNSTRllGCION FEE 10l -0€14••4#8-0_M
TOECIM741CAL P—M, 1Q1-000"1.2.1-1100 $4700
ECWi" CAL rET, 101,4100-424-000 $111.78
Pk.[X�if33r�tEir'h1; 101-OW419-Wo 9148.1103
CT tiO?3C', M011014 t: EF - lt':Slea e A I -0(1(1-241-41(3C! $9.0
C;t�i►iL?lti!"i t ` ► 101. -OW -423-000 $20.00
Nf,1tA&fj Uo"%'CI E i.,tla 725-000443-342 SZO45.46
Cl:7R-TC11'. L C:(JNSS"M:i.l4.` ION .AND P .A 4 (`, REC K
LESS PRE -PAW Fl 'S
50,00
J
y �y A�yy p r p, T �t ,1�ry�`�r
;^ 1 TOTAL1!: &'R .i':i.A'.w�1.OV. 14tAf.Ti
SEP 2 � d��1��•
- g0,41it. i7
RECEIPT •
DATE
BY./ "'-''
DATE INAL D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
�j�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
.b age – 48' „Y,
Return Air
Steel
Combustion Air
Roof Deck
—cC $
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing Td L
Compressor
Insulation
77
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
Drywall - Int. Lath
468
Final
Final
POOLS - SPAS
BLOCKWALL APPROV LS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
f
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster '
Sewer Lateral
_
Pool Cover
Sewer Connection
`m � d
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
r
c
Final
77
l9tility Notice (Perm)