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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
6140 14 B /"'131199
�r
vDate�!'�? !'�� Signature of Contractor
OWNER -BUILDER DECL' RATION
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 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.
STF Al 7h: f"f Nn. � 1371.095
(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 ptrovisio� of S tion 3700 of the Labor
Code, I shall forthwith comply with those provislotns.
ate:, : tf i I lb°+ Applicant 11, E�
Warning: Failure to secure Workers' Compensation coverage is unlawfuliand
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold. harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct.,) agree to comply with all City, and State laws relating to the building
construction, and hereby authorize reprise%tWives of this City to enter upon
thelbove mentioned property forospection purposes.
Sil
gnature (Owner/Agent) ./ 0 � Date �/ � 'jni
BUILDING PERMIT PERM' ye15a_20CONTROL#
DATE , / VALUATION S351JI88.30 LOT 10 TRACT
8,296
JOB SITE
ADDRESS lii i)30 4 tach E, BRISA
APN 49-210.004
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.1).1` ESE'R ' pi,,v F','.o.°it%I r
SVIMS C0N.'9 iRUX: 100
P.G. Box l 116
79-295 RANCHO LA QUINI TA DR.
LA -M CA 92253
LAQ1_f[9FA CA AZA.
(760)771--1941 CMA V96
USE OF PERMIT
SINGLE FAMILY DWE LUNG
SIFD, PLAN* AI, LOT 10, PMMIT DOES NOT IN4: LUDE W40CK
WALL OR i'x7L.I).t.A-N C.KECK r b -H ltgDUCEI? 710% E'0R_1VlUf. fH_1LS
ISSUANCE, CSR SAIVIE PLAN TYPE.
CUS (rNI C:ON1STRlJCt"10N ' 4,243.00 SF
PORC3INI.f TIO 5220 S%
QARA0UCA1. P0R1' i 1(00 5.1+
ESTI$i1[l ikl.l) OAST OF C:MI,ST1t:.FMO N
35.9..1`3.3°.340?
Pit,'RMIT FEE Sf1MN,L RY
C.'CEN31r.RLfC_r10N E'I?.E 101 tifN 41t3!)Si0 $1,521.
14r(X F FT 10) -OW.-439--
318 g3ftR.73
'NIVICIIANIC.AL, I'TIZ 1121 -OW -4211.000 $1316 U
1`x,:6. 'C iG"Ai FM 101-0,00-420-000 S246.71
PLLiMCil.tai; T 101410-=119-000 S4u9.0U
;4'1714,0N i V0110N 4".E - RE+4T3 101-0ft{1�941-f{0)0 $i5 14
CftAi1ING M,131 101.0 00-•12.3-000
1NrFf4AF>'FkVC1'I1NtJ'sME :225-t3Qf)-443-342 S�.OE3ti.i3U
Aker IN PUBLIC PLA(.%S - RESKA' 701-000-255"00
,135H-"4`MAL CONMI 13+NTIGN AN D P1_.AN CHECK
$9,102.05
LOSS Mr. -PAID FE TS
$0.00
TOT AL 9'L.ixMIT FE1(.14 DUE NO'VV
$9.102.05
J1
RECEIPT
DATE
BY J
DATE FI ALED
INSPECTOR
71�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs . C
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Ducts
Slab Grade Z��� _
Return Air
Steel
Combustion Air
Roof Deck — ..
O.K. to Wrap
Exhaust Fans
F.A.U.
Framing 01>
Compressor
Insulation _ p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail insulation
Condensate Lines
Party Wall Firewall
Exterior Lath (2? -2 Q (�
Drywall - Int. Lath ro
Final
Final !�
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
I �` 7/`
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
Utility Notice (Perm) l l�Gf
COMMENTS: