9701-051 (BLCK)LICENSED CONTRACTOR DECLARATION
I h4reby 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
MP
�_� 474
Date �— Signature of Contraetor
OWNER-BUILDERMECLARATION
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.
('K) 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 STAT PUa, D Policy No. 1 ee
(This section need not be completed if the permit valuation fisOfor $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 l ecome subject to the
workers' compensation laws of Calornia,tand agree that if I should become
subject to the workers' compensatio proV dons of Sectron 00 -0 -of the Labor
QddeJl_sF�all fotthAith comply witVro" pr�vhionsr
Warning: Failure to secure Wo kqfs' Compensation coverage is ufilawful and
shall subject an employer to crimir5al 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& each personate r
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, indemnity
& 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 withiri 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 thag the above information is
correct. I agree to comply with' all City, and State flaws relating to the building
construction, and hereby auto orize epresent'atives of this City to enter upon
the above mentioned property or in pecti.• �r/oses. %
t ignature (Owner/Age Date i !
BUILDINGPERMIT PERMIT# CONTROL#
G
4595DATE
<�� VALUATION �✓if'fit� ' LOT TRACT
JOB SITE ADDRESS ill a�ii'T!,Ii1P#9L+. Ftr�i�a`a lit i
APN 774,101-4-415
OWNER 6 V
CONTRACTOR / DESIGNER / ENGINEER
iti?'a�+ � ASIIII4GV; ki j 0-35"
42333 iVe1£+fl.iN4 .i�] ST'. #315
►ak1,L.A lit?:Lift'!' (�a1, tl'226!
1Id1.3 M I -A -ti RT CA 92260
ft;t i'tl;-9365 t:Ttl. 21 W
USE OF PERMIT
a:?si L,.r,., .1-AINiNki 'WALL, 037V S-111.
4 1-1'. L't'A'LL Lf'
��Sii'.T sR•L�.€ 9iri� �5�3''�� �:sr ��,°�'i,��i1:+ii�iFa'�ii6�
i,��a.�t�
COON3TRUC110N FEE S-14.0)
'N,
. r -
COINS" RU `►`'lGN AND PLAN (711PCK
D& CESS PRE -P ITC):E13rS
$001
®
wM'C`AL P.E,$01[Y FFM44)[Y► tE NOW
&%410
JAN 10 1997
CITY OF LA QUINT r;w?D
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
X4
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
BLOCKWALL APPROVALS: I
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam 41Q -1
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
0. K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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:
,