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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
14158 c3 �C- IUf3if�►7
Date k,-1,#
Signature of r � /r
OWNER -BUILDER ELBA AT ON
I hereby affirm under penalty of perjury rtl 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.
( 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.
�" f4Y.`i'31 INS: C'O.
(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 tot wo kers' compensation provisions of Section 3700 -df the Labor
Code, I s4Yf, fortwith comply with those p ovisions.
Warnin§:'Faifure to secure Workers' CompeTisatiori coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set. forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant AD
any permit issued as a result of this applicaton agrees to, & shall, indemnify',
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize repr se entatives of.thiis Cityto ent 'r upon
th above-mentioned property,for'inspection-purposes:`
Signature (Owner/Agent)—' .� -�� Date -/,/--7
BUILDING PERMIT PERMIT# CONTROL#
G rY 9704.024 4
DATE 4/7/5}7 VALUATION &116+767,40 LOT 10 TRACT c5,17!„�{52
JOB SITE 4S.280
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�.. F. !'. s iJ,. a {.. w�,%,rr �Si.,[. it.iTfti eAsi�.i.��'�:i i�. �s�
l.. �a.V` 1 �Jsr.�i..�s(�i �r Ci.,..ir�.±{�Yi �•klitJ�l•i.e.e�.
15-33 S "U” 1'
SAN 81 Id AR131' j E CA. 92408
SAN RERPIE1:R1 1N0 CA 97408
('JriM81-0007 CBLt1 2120
USE OF PERMIT
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JAIL .REY,1N Ai.N °+XBR, TiLAN CHECK FEIS t`d i:LXEC@3 .BY 7MA F(At.
fv$.ULT.IPLF TSSt.ffi, OF SAME FLAN TYPE-.
trr 411kcr GOONS`rRV'CTiO.�N, Z 0173Ak SF
l�ilf�tikCr.r1EL}'GtSL'J` 35<).tJt) alp'
;11VT'J 1X.'aTK0 MITI* OF CO N's -TRU IFION,
110,74,7,40
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PLAN �ffkyc k ��� ;tf)1.•,Ci1)ti-439^:$18 $145.05
r;,f?i��(tSY�� t�tiC, i'f10N,Ff� ;j.(0-000-��.1 OOO $FWoo
'A1W�,Nt4v,P 1, a'.0 101400'^471-0Vii
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a't'OfvOYNtO'1'KNIJ'FEE-.RFNP) 101R000,241-* _ t'13..tis3
(11VIAD111110 0113 101-00-423-M
f1JN.f"t��; '3'i�f it ".1`i3ks Fac, W-000-443-341
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PC11�-TOrAl. i:.'O �'7°,!"Zt.1GTION AND TILAN C:1°f:(:l_.K
PAID. LESS g; :-PAIT)FEES
$0.00
APR 0 81991 t)ii*�1;NO V
RECEIPT
DATE
BY %
DATE INA
INSPECTOR
iu
_
-
.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans '
O.K to Wrap
/
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate', Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
SLOCKWALL APPROVALS
POOL$ - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
O.K. for Finish Plaster
Server 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 7
Utility Notice (Perm)
COMMENTS: