9905-307 (BLCK)c
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
291728 I3 y; o�l3ir2Gt
Date "� �j` iSignature of Contractor -)`4 w -•
t
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&RC. for this reason
Date Signature of Owner
V
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.
S cI have and will maintain workers' compensation insurance, as required by
tion 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.
2 29
(This section need hot 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,
1'6hall not employ any person in any manner so as to become subject to the
workers'.,compehsation 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 forthwith comply with those,provisions.
Date:. Applicant
Vjar r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltie's-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
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
the above mentioned property for, inspection purposes.
•ySig� re (Owner/Agent) "�''`; . <,/`,P_o' Date - �+ 4 o`•f
BUILDING PERMIT PERMIT#
9905-307 '
DATE VALUATION LOTTRACT
70 BIX2189 U 26
JOB SITE
APN
ADDRESS .54-330 :4.VENW ii RAf`URE-7i
774-244-005
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'1 -HO IAS BUFFIN
WILIJAMI RUSSELL R001' S
54-330 AV.I NIDA RAMIREZ
46-900 JACKSON
L,A.QLJIWrA CA 92253
THERAiM, CA 92274
(760)399-1200 C81A 1954
USE OF PERMIT r
OFNERA1., BUILDING
13tf'1..�.•. IU°''ir1iC313LtislAiMi[�i0 WALL, Ci`I STANDARD
4.Fr. WALL.. L:30.00 Lei
H-RTM.tiMEM COST OF CONSTRUCTION
21p;30 t)
PERMIT FEC SUMMARY
C,'O>`J. 'RI1t 71ON FEE 101 -OW -418 -OW
t
MAY 2 41999
` CITY.®F LA QUINTS
430370iA3..f fIAI'TKi;ft 1IlJAf AND P�I..A1�lpp(f� H1ECtrKti
1;511100
LLc'
C LL;S� 11R;-1'�1ID FEES
$0.00
'rC2TAI, PIKI IN411 if:•EFUS' OUP, nMV
S54.0
RECEIPT
DATE
BY-
DATE FINALED
INSPECTOR
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 _¢
F.A.U.
Framing
5zCompressor
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 I ru
BLOCKWALL APP W OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
T
Main Drain
Bond BeamApproval
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVALS
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
O
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
Utility Notice (Perm) ?�
COMMENTS: