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LICENSED CONTRACTOR DECLARATION
1-he'r—eby affirm under penalty of perjury that I am lice' nsed 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.
Licens Lic. Class Exp. D
q1 t 93
Date Signature of Contractor—I �v
OWNER -BUILDER DECLARION
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
( ) 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is ippyq�jy 0
.y6V kers' cor4pensati n insurance cager,&pq 'are:
gL
CarTier Policy No.
(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 SectioJI 370(11of the LaAr
Code, I shall forthwith comply with those provisions.
Date: _9_.__1_Z_—_/_/_Applicant_
Warning: Failure to secure Workers' Compensati n coverage is unlawfu,(and
fl
shall subject an employer to criminal penalties aicivil fines up to $1 00,ObO, in
addition to the cost of compensation, damages a s 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 Wofthis Cit to enter upon
the above-mentioned property for inspection pur , ose
ate
Signature (Owner/Agent) ate.
PERMIT4(ow4m.) CONTROL#
BUILDING PERMIT
R/ 8/96. 1*76.1-57 11SU 3846
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER ENGINEER
DEWEY S & KKMIMN fJOLLIDAY
)MMES H. S0,0011 CO.
54-135 AVEMDA BERMUDAS .
35905 DILLON RD
LAQUIKVACA 9T2.5-3
M1010 CA 92702
(61(9)347-5399 CI1LR 121[7
USE OF PERMIT
RN%104�0411A.J, ADU)MON
CQHVIKV KXINTING '10) &K UAKINUE, INTC) LIVINU SVACEI
*)J)I)'W%W 6408 F. OARA(1115
ClAkAOW' CARK.110' M00) SF
USTMUNVED COST OF
10 1_4)00.42 i _W0
0,U'Zf7,ZICAt. FEE
IP 1414 411- 4 1 ti -MY)
SM-TUFAL. CONSTI RX1010N AND PLAN CIMCK
LES -5, 11RE-PAID FEES
$0.00
lrcyyv� 1, eu "M n, rc ws 1) 1) 1P. Now
1 9
AUG 0 9 6
By ---
RECEIPT--
DATE
BY
DATE FINALED
IN. SPECTOR
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 IAI
Compressor
Insulation 77-,71 -7 (A-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 4
Drywall -, Int. Lath
2W16&9z
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
SetBacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
0405 1,772-
Underground Electric
I Of
Underground Plbg. Test
Final 1 11
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 IF r
Lffllfty Notice (Perm)