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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 DATE
Professionals Code, and my License is in full force and effect.,
License # Lic. Class ,�^'' /Exp. Date
714:1R8 13 f'
�'', y '
Date � Signature of Contractor.- - -•
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&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 mamtairi 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. . 11
( ) 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 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 Section 3700of the Labor
Code, I shall f , rthwith comply with^those provisions.
Date �� Applicant �. r .•d^'--�"�--" s . �.
Warning: Failure to secure Workers' Compensation cove age is unlawful and
shall subject an employer to criminal penalties a d 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 Iaw'ls relating to the building
construction, and hereby authorize.representative`s of this City toenter upon
the above-mentioned property.foir inspection purpo_sesll
Signature (Owner/Agent) --� Date_
OWNER
BUILDING PERMIT
VALUATION LOT
n ) . $9I),1t g.".
RRIDGETTE WAY
CRNIURY CROWU'l COMMcrNITTr:
185 SO. "Uar a MEM— A, :ME. 9200
SAN U:MARDIN' CA. 92408
USE OF PERMIT
1351. RE -Y 00,LA Q1:31Nr.rA NiO_ .R,TE
LAN 31't. .<r'
TRAC*I* C4 N"3, :fR1.JCN110N
OAR AO&C'•ARXIOR'P
PERMIT #
96tif ONZ
APN
CONTROL#
TRACT, 3536
604-342-608
CONTRACTOR/DESIGNER/ENGINEER
C'EA1TURY CR0UMLL C01t3rRA-11TIES
1515 s0. "D" gru r, .siv- noo
SAID BERNARD1NO CA. 92408
(1)04'13P1-,6007 ' CBI. # 4,320
KIVANIi N'AGUII.AR.ASSOC;.
5459 PA.SSER0 A;VV,.
fUMSI13R CA92505
1,443,00 SIF
615.00 31
- l'.ia711Mx IT,1.).Pt:4.�a71�. OF �..\'dA�.7.1. RIM—b.A0Jt
�r
�[►1N,1t1�'I T N ll+ E ti•I1MINIAR
P3,AN 04€11.CK FE31
$504.98
CON911.11RUC'1'lOI31'M
101000-418-000
S539.00
1411;C'FiA IaIC A(, T� LIQ
H) i-000-421-040
347.00
1 L:L"•C 1'ittt":Aim f Z :
10.1.000-4204*0
SIM78
PI17Aa131�fXaM f
!(J!-00-4!tmm
$148.04
S9'c YNO 100TION RX, RtESff
104 -000.2 it i -000
$9.09
QF1AD1NGFAM
101-000-423-M .
U60.00
dA1Fi iV.,VfRTJC' 'LfICC Fht•i
225-000.441-M2
r.
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SUB -TOTAL L CON51 RUC"! sON :AND PLAN CHECK $3,485.31
�. LESS PRF,-i'AJD FE $0.013
r I
'�'� Tf1.kL, l'.ER.Nf1�':Flr4 I3[.11r kl�O4 . $3,41131
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RECEIPT: DATE BY DAT FI ALD 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.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APP OVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROV LS
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
Utility Notice (Perm)