9610-089 (SFD)U)
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LICENSED'CONTRACTOR DECLARATION
I hereby.affirm tinder penalty of perjury that I am licensed under provisions of
Chapter 9 (comAncing with Secti6n 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
1064 1[0 B
fill 1,1
Date Signature of Contractork- lrl�e
OWNER -BUILDER DECLARATION
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).
( ) 1, 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.
I have and will maintain workers' compensation insurance, as required by
Se6tion 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.
MNITU INSURANCE Z04Z0629,11
(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
Pode, I shall forthwith comply with those provisions.
,/Date: - Applicant
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
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 suc * h
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.
ignature (Owner/Agent) t 1 14' J_ Date_l��- r1l.
PERMIT# CONTROL#
BUILDING PERMIT
9610-049
4472
DATE VALUATION 1
543,0",00 LOT TRACT
JOB SITE
ADDRESS 58-60.1. HANFIELD DRIVE
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
CHARLES MOWGOME'RV
11JR11IN CONSTKUMON CO.
I -A Q01WrA CA. 92253
-
(619)777-7.611 C111A 3751
USE OF PERMIT
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still-111-Y110AI, CAWS-MUCTION, AND PLAN CHECK
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LESS PRE AIDFUS
TO'FAT, PERMITFEWS 411119 NOW
RECEIPT
DATE
BY
DATE FrALED/
Ity 3,D
JINSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING -APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
""ilab Grade
Retum 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
I
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
Maid Service
Sub Panels
Exterior Receptacles
G.F.t
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
a '
s
_ CITY OF LA QUINTA
E - BUILDING & SAFETY DEPARTMENT
777-7012
INSPECTION REQUEST LINE
777-7153
j Owner MONTGOMERY
I Contractor TURPTN CONSTRTTCTION
{
j Permit Number 9610-089
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
I
JOB ADDRESS 58-601 BANFIELD DRIVE
SFD - PERAUT DOES NOT INCLUDE BLOCK
I
WALL OR POOL
TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL
1 MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
DO NOT. POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB —
I JOISTS&.GIRDERS
ELECTRICAL GROUND WORK
00 NOTAUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST () 1
HEATING & VENT - A/C
FIREPLACE
ROOF —
BOND BEAM i
O.K. TO WRAP
GROUT ❑ 4' ❑ 8'
FRAMING
INSULATION —G%.
PRE -ROOF
+ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR �-
EXTERIOR LATH
POOL PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK
ELECTRICAL
PLUMBING.
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS
JOB COMPLETED l
TEMP POWER i
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
7/96 TURN ON UTILITIES OR OCCUPY BUILDING