9705-104 (PLBG):.r •.
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of p'eriury that I.am licensed under provisions c
Chapter 9 (commencing with Section 7000) of -Division 3 of the Business ani
Professionals Code, and my License is'in full force and effect.
License # gy Lic. Class Exp. Date
A.6 ,'.d -.'^^yam, 1: 31,98
Date { `y 7 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor';
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their soll
compensation, will do the work, and the structure is not intended or offered fo
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with license(
contractors to construct the project (Sec. 7044, Business & Professional:
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 worker:
compensation, as provided for by Section 3700 of the Labor Code, for th(
performance of the work for which this permit is issued.
l I have and will maintain workers' compensation insurance, as required' b,
S`ection 3700 of the Labor Code, for the performance of the work for which thi;
permit is issued. My workers' compensation insurance carrier & policy no: are
Carrier - Policy No.
S'1'f1.1'#3.i'1'tib�U
(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. th(
workers' compensation laws of California, and agree that if I should becom(
subject to the workers' compensation• -p ovisions of Section 3700 of the Labo
Code, I shall forthwith comply with those provisions.
Date:. /915?r„ Applicant/! `---
I (,1
Warning: Failure to secure Workers' Compensation coverage is unlawful an(
shall subject an employer to criminal penalties and civil fines up to $100,000,.ii
addition to the cost of compensation, damages as provided for in Section 3701
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safet.
for a permit subject to the conditions and restrictions set forth on hi:
application.
1. Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pu�suantt(
any permit issued as a result of this applicaton agrees to, & shall, iridemnif.
& 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 i
work is not commenced within 180 days from date of issuance of sucl
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 i;
correct. I agree to comply with all City, and State laws relating to the buildin(
construction, and hereby authorize representatives of this City to enter upol
the above-mentioned property -for. -inspection purposes.
qq
/Signature (Owner/Agent) 7` I - i--- --- -i~- Date
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✓CONTROL# �
BUILDING PERMIT PERMIT# �
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97055-104
5168
DATE VALUATION LOT TRACT.
5/1-9/97 $1.41100.4)(31
JOB SITE
ADDRESS. -7'9.� f���. 1� L� 1A'S.�Sf l: .
APN
, 774-12i-022,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
L.A. QUNTA. ft .I..PvB � AL""1'
C.
53315 AVTsAi'1i7A iv�Ir<lltL
5i-001 f IS itiN(JSN'ER
L21t:
LA WITTrA. CA 922.53
LA Q'U!'tV'TA
CA 42253
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f Ifa(11 �-t.3Z8
CgLif 526
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USE OF PERMIT
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ti M.i14:'I N i.A0 0 LS
4
1'. STIC4IXAVl1 COST OF CONSTRUCTION
1110M.0k
PERMIT PCE SUM MARY
faLUM(1INCEVHE.... i(31V}:!t2 10 1 -O(V-419-000 $30.00
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t,"'i1PJCI'R.l.�t"�?C)Pl -AND 4.A.f� C'1•#1�..
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%�() J{1
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,.-� LESS I'Rt:TAID FEES
19199
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`!OTAII.,
PE"RMIT 1910:8 ME NOW
$30100
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RECEIPT
DATE
133 %
DATE FINA LED
INSPECTOR
1-7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
F 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 Wail 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)
f 1
COAC..vA LALLEv WATER DISTRICT' r
'CASH RECEIPT DETAIL 6300/
Received Fro1'V Date:
Address:
Account No. Z �! t(s) 2 Tract' S y Z Z
Service Address Z G.A.. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ DetectorCheck(s)
❑ Meter Surcharge c
nitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water./ Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL $'
r Remarks: 4.+
❑Copy to:
Cash Water Service
Check
Money Cashle,
Order D-038(11/89)