9808-189 (SFD)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
7254124i3 7131/60
ff i�
Date �f ( Signature of Contractor-wo.,"'{O'er
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 37o0 of the Labor,Code, for the
performance of the work for which this permit is issued. ,
A. 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.
ARfi,E1.I.4CAN 12M. CO, MC30760300
(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
CC016, I -shall forthwith comply with those provisions. %
(Date: c..r,l/ Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety p"
for a permit subject to the conditions and restrictions set forth on his �
application.'
1. Each person upon whose behalf this application is made & each person at {
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null,and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building,:
construction, and hereby authorize representatives of this City to enter upony�
the
-above-mentioned property for inspection purposes.
Aignature (Owner/Agent) l-�'�^"^ ^� Date
PERMIT # CONTROL #
BUILDING PERMIT
9408.1819
A �p
DATE
1l VALUATION 530.5,22.160 LOT I TRACT 28..14 9
/I
JOB SH
ADDRESS , ( 79-102 UGA.
APN 769.6,70-031
OWNER v
CONTRACTOR / DESIGNER / ENGINEER
DESERT 1401151:0` MO.
CATER, X9 Ri St'1aENP f1AL CUP STRUC'1"ION
5 PARK PLAZA 9TV 400
51)ARK P:(..A7-11, SUM E 400
F4I tIv"2~: CA 926144
1R INE CA 92614
!�
(714)251-6100 c'"13r €# .15072,
USE OF PERMIT fs
rq
SINGLEFAMILY DWRUJNY.
SrD - Mift-t; 1, .LOT# 1, F,%'9lUxi t iOE8 NOT MOLTUDE; LALOCK WALL
OIC. POOL,
CUSTOXI CONSTRIfC-130N ,fi X3.00 SL'
POIC't4fPATIO " . ' 312.06$!,*
w+�,"�4' RAOEICARPORT 695.00 SF
EyS'�:[1�11�9.�'ED C'i?�`.1, ���€' �'Dlti`ST'�ti�'i"'�`€®N
30:1�,2z2,b0. .:
�)i g. �y q.
6" V1R1!% i FEE E SU ta�N"i.AR ZA
�
CONSTRUCTION FRE It11-000-4114-000
PLA14 CtMC , M, 101.-004.1-4V-31 �i
MCRAN1CAL FES It51^000.4421-000
ELECI'4UCAL ME io 3.-0011•-120-000
Px.t:lM-13M k'E'E 101 -000 -419 -testa _ $214.50
S1Tt<)ISC? WYMNI1 _'"*�11Si}� 1111-000-2411>0010 $30.52
MAD NO FES 101-000-423-000 $20.00
1•NFRA.Tf1dJCTU .E r t 2215-000-4443-3E42 56,000.00
ART IN PUBLIC PLACES - RESW' 701-000-25 +-000 $513.06
r:EF, n:PO-SAT 1x.01-000.4 101-000-439-348 4750JR)
R
A
1ti M,CONS zi R.IJCT1t�N A..ND p1.•AN Cfil""r1k
$9,603A
SEP 11 1998 LESS PR E-11"AdD FE LIS
--.5750.00
TUTAL o ERN1 FV F�I EN 0UF,NOW
.r6T( OF LA QUIN a a��
RECEIPT
DATE V
BY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
,� g� %�
Underground Ducts
Forms & Footings
-_g _
Ducts
Slab Grade
` 4t
Return Air
Steel
Combustion Air____
Roof Deck
O.K to Wrap
_
U - Cj- r(f
— �� _
_
Exhaust Fans05
F.A.U.
Framing
�� _ !�
Compressor
Insulation
Fireplace P.L.
10 _
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final 11 2-a -a
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
I
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:
I-+Zv►^�,v6^�T�.� �j`� 5� �7 �y
Final /
Utility Notice (Gas) l �d
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
t
Final
Utility Notice (Perm) l= 02 I •�.