9703-095 (PC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I ani licensed under provisions of
4 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
'109.907 D3 c61.
Date Signature of Contractor'
OWNER -BUILDER DECLA TIFiA ON
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.
W 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. .
(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
Code, I shall fo with comply with„thos'e provisions ���
Date: .�'S •c14 Applic t
........ +�_ rr
Warning: Failure to secure Workers' Cor2l?9Vsa"tion-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 ti& 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 qt 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
/Signature
he above-mentioned property for inspection -purposes (Owner/Agent) � � y Date -_ `_S ���
PERM c# °°NTR°`#
BUILDING PERMIT �7F�YaS 4857
DATE VALUATION LOT TRACT-
1D8�.A3di .
1/21/97JOB
SITE
ADDRESS '748P-435 RtCo,� MUVV 11.E
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
J,)0' 'I`0 V 5:KVINGS LOAN
i&a35 H'4 Y I i l
74877 som oRIVE, Sump -8
.1,A UYINMA .. i A, 91'2153':='
PA:I;Ni D. Sis'!I T C V260
X7,60)1 ;-7079 CBU I :18111y
USE OF PERMIT
M.iC111G
CSS',`3't'Ai.[, ,WWNlitifT I+ ,t+fl4
w N01 -P: 4'M-. N1,i,l` F'. XS EK) WIU R) Pf.lit 1:f131;,8VC 107,5 FOR t1.'iA1?L.JX)N.:i, `
•
f.
s
4::rD'NS':I''t2tf�'!`lc�tv.)�i:1;� 1�1-f)f�.)•�1��{?O �'�J��j
.
j;
164..
.ESS PRE, PAID FETS
$0.00
..
' 2 5 19914-o _'u, .00RM IT FEEN DUF NOW
MAR
1t"rh
RECEIPT
DATE
BYgYE
INSPECTOR.
'a
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
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
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
Pool Cover
Sewer Connection
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
Final
Utility Notice (Perm)
STATE OF CALIFORNIA • STATE AND CONSUMER SERVICES AGENCY
STATE OFCALIFT OF CONTRACTORS STATE LICENSE BOARD
MORENO VALLEY DISTRICT OFFICE
FETE WILSON. Gov.rncr
iY-�.p5.�.,� •
12981 PERRIS BLVD. CITY
SUITE 208 vT► OF 1. Q nl 1111), TA
MORENO VALLEY CA 92553DATE: 03/18/1997
(909)485-6011 MAR 2 4 RECD
CONTRACTOR:
COUNTRY CLUB AWNING
BUILDING f�I�iu ;,��'` .'y LICENSE NUMBER:
LIC 709907.
FILE NO:SW96021522
PROJECT ADDRESS:
CITY OF LA QUINTA 78-435 HIGHWAY 111'
BUILDING DEPARTMENT LA QUINTA CA 92253
P.O. BOX 1504
LA QUINTA CA 92253
W have received .your request.jor., an -investigation _by,.• this agency._.•If.;your" contractor..is licensed._.
by this agency, we have notified him/her .of your complaint. This may" result' in a'solution to, your
problem prior to further action by the Contractors State License Board. After you have been
contacted by the contractor or after seven (7) days from the receipt of, this letter, please provide
the information requested below and return the form to us as soon as `'possible.
i
Sincerely, "
DAVID C. REYES r „
CONSUMER SERVICES REPRESENTATIVE
CONTRACTORS STATE LICENSE BOARD
The following information is requested from both the contractor and the complainant.
Please retain your file number above for future reference.
WPL5
Settlement was agreed to and complied with on 3 2l� q7
(explain settlement agreement- below) (oats)
Settlement offered, but it was not accepted. (explain below)
No contact from the contractor within the aforementioned seven day
contact period.
If the*'complaint has not been resolved and 'if' you have not already done so- please send a copy
of your contract or written declaration of oral contract and proof of payment. (A COPY OF FRONT
AND BACK OF PERSONAL CHECKS AND CONTRACT IS NECESSARY)
Remarks:
Bin #
City of La Quinta
Building & Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quints, CA 92253 - (619) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address:
O«ater's Name: QaF l/
A. P. Number:
Legal Description:
Address: '1�e&07 ^!/J &Z
City, ST, Zip:
Telephone- ,%�G y�l!'r!pr!t'
Project Description: AyA Ste!
Contractor: 2 dal,474jj C
Address: 7,Cl
City. ST, Zip: e/-7
Telephone: A, e — Zf4, -690 (n
--
Z -V &X l/7.f%fil�L'c�
State Lie. #: %D CJ lJ % City Lie. 9:
OL q� WI I VI�i/ Gi I'v►V) C� �o(� ( b
Arch„ Ener., Designer:
Address:
City. ST. Zip:
Telephone:
State Lie.
Construction Type: Occupancy:
Project type ( circle one): Add'n Alter Repair Demo
Mame of Contact Person: /7/�/ll/% �a/J/J!/J
Sq. Ft.:
Stories:
t Units:
Telephoner of Contact Person: aI -
Estimated Value of Proiec ' �QQ . ew
APPLICANT: DO NOT WRITE BELOW THIS LINE
Submittal
Req'd ,
ReCd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for
corrections
Plan Check Deposit
Truss Cates.
Called Contact Person
Plan Check Balance
Title. 24 Cates.
Plans picked up
Construction p
c� Q
Grant Deed
Plans resubmitted
Mechanical
School Fees
Reviewed, ready to issue.
Electrical
Subcontactor List
Called Contact Person
Plumbing
Contractor Info.
Date of permit issue
SAM.
Cid' Business Lie.
Grading
1A"orkers' Comp.
Infrastructure
Planning Approval
A.I.P.P.
Pub. 111s. Appr.
t:
H.O.A. Approval
'Fire Mar. Appr.
H. Dept. approval
Ag. Approval
Date of final inspection
Total Permit Fees
A-
1.%