9810-089 (SFD)LICENSED CONTRACTOR DECLARATION
rA .7, I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
r- CY 69 1684 13 1/00
oZ r- ate 14AWOKignature of Contractor &414
CO O "o
tp OWNER -BUILDER DECLARATION
HLU r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
C0 () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
rn
Z WORKER'S COMPENSATION DECLARATION
LO CL
Q Cr I hereby affirm under penalty of perjury one of the following declarations:
r H O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m_ Q performance of the work for which this permit is issued.
Q () ( I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
CL 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
w O STATE �A; 1 14=31-97
J (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
3 subject to the workers' compensation provisions of Section 3700 o the Labor
Cypdie, I shall orthwith comply with �o a provisions
k ate:! / APPlicant
Ice
-.,.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, 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 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
theeaaboGe-mentioned
`pro�i nertytpectp .poses.
;3gure (Owner/Agent)
1 Date
G���
PERMIT# CONTROL#
BUILDING PERMIT
DATE VALUATION S104,769440) 169440) LOT 40 TRACT A 4 `l q
7 7715 iPJPK�,WFfikV. �,A1D.t ' JOB
APN 6054-04I)•-021
ADDRESS
_ T v. -4k) i • , . ' 4
OWNER
CONTRACTOR/DESIGNER/ENGINEER
"INC0x t�i,�ILF,�$0�y0111tP.
.�r�iy�tg:,1i0nMC1.1_'Ct.;lZP..�
i 242 Yir... i Y W YY :%( iry� �4�
i282 W. JL URO W .f•: i• YY .i�
UPLAND CA 91185
1J.iAL&NO CA, -X1.1785
USE OF PERMIT
p q
�
SIMAR ?f�,t11,Si...C� tiVkh3I 1.1 -NO
4F1},.i.f'rT. it 17, PLAN _13-3, PEAM ` ih�.i S 14 T INCLUriTiT4LCPCfi
WAIJ. C1it.i=00L. PLAN E'IAfaC.KMZ RUDUC K) BY 7''r`;bFOX AfIL9.`t`IPIX
13SUANCI`, OF SAME PLAN `1 YP13.
TRACT 'ONS'ITi1J 'ilCiitii 1,696.00 S
.PORC'f!/PM 1O 94.90 Sr.
CARA 1FICA"O.RT NS3.0 SE1
ESTI�i�ATE,DCONTi ®t's;.0NNSTRU , ION'
1334,70.30
PCIRMIT VCR SUMMARY
CONSTRUC KIN FRE 101-000-418-000 56570)
KAN Ci MCK ITT3 to 1-000-0.9-31 R 11.138 'A
1V1'GC.'tfiANICA L £A39 1.01-000-421-000 $66_010
E1XCT1 0.CAI.: H—S 101-000-420-000 51.19.5"
ktJiv arNU• f .3T- 101 -OM -419-000 51423.Ut�
;rFRONt %0109TION1 -R"_In 1x11 -MO -241-OW $100
(TRADINQ J EL 101-000-422400 11Zf1. 0
1NFXAS',t`RUC2'LiRL*, FERE 2ES-000-443-342 $2,32.9.19
ART gN PLFA_LIC'PLA,C-F-11;R*&410 701-000-255-000 �t1J�2
t
q
it-`.(YrAL C a�?Sl F?LI�?Tq?�I AND 1't1�1 t1:C#�,
�
,u►p,tlx
LESS PRE -PAID k E1.S
`0.00
TOTALP1,0'711NIff FMStiillt:NCiW'
53,50.93
-DEC 30 1998
RECEIPT
DATE $ BY
DAT I ALD
INSPECTOR
r
r<
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
/a
Ducts
Slab Grade
Return Air
Steel
_2
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
9
Compressor
lnsulation D
Vents
Fireplace ( L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
7777-
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
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
9/Q9
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
_
Gas Test
17
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)����