9701-081 (AR)(• 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
1.41.18 B 101'31/917
ate t tf ! 1,rt-1 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 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.
00 1 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.
ZEN] Iff I 1NIS, CIO. lfl9'2�3oiC,�IJI
(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
subl'ect to the workers' compensation,provisions of Section 3700 of the Labor
Glide, I shall forthwith comply with those provisions.
Date: 1 (% t ^' 1Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, 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 laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned proo6i y_for�inspection purposes.
ignature (Owner/Agent) It ' Date 7.
PERMIT # CONTROL #
BUILDING PERMIT 90/01-081
DATE '��E�G� VALUATION $1$.S LOT. }� TRACTJOB SITE
-6
ADDRESS 365 C.;Alht.liNO A�AVL APN 04-191-0,18
OWNER CONTRACTOR / DESIGNER / ENGINEER
JR -ANCA -10 OC;O7'4..W LP 11"IE TT'1 RY
1535 S 'u, S''1; S 1 ? 1200 1535 SO. "13" �`t`R IT, STF. 9200
SAN 13Ee.R-NAl ANO CA, 92408 SAN BE RNAiMINO , CA. 92408
(909)3131-c>c>n7 C E3U 2 r 20
USE OF PERMIT
AWN
`3'I`cACT CONS`1'l 1..JC.,`T,EON
M.00 3F
t*CRIM f` PCE 54.1MMARV
PLAN C k11 CK FFF3:: 101 -OW -4,19,318
r()N1ST_1t?)(7`1[011q Fp;5 101-000-419-000 111 �i.C)i1
MECHANICAL FIT 0100-0-1-000 �lS.Ctt?
VL1-_,CTRICAL FEE. 101 -t* -420-000 �r25.22
lyA.1,lN113lf`fC1 FFIE 101-001-419.000 SxW�.rn,
1'C.1+C' )M(*Yr'ihN) FER, » RE -3P) I0 t -4)00 -241 -OM $'1.1u
INt iZ,4 1 I €2.t r%,". 3vji 1:1:r 225-000-443-3421 056.75
ART ?2ti.F'E1BIA, .`et A{ _: 701-000-2 55-000
SSUNTO, .'A L, CON5`1RUC:rEON AND PLAN CHECKNOW
PRE-PAWFEES
$0.00.,
JAN 21 1997,
CITY OF LA A11AB'1.
RECEIPT
DATE
' 7
BYE
vt
DATE FINALED .. -
INSPECTOR
INSPECTION RECORD
r OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel 1007
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 LZPOOLS
BLOCKWALL APPROVALS
- SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APROVALS
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
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)
COMMENTS:
C
TRACT 24517
LOT 3g
ADDRESS: I/4' 3(,C
►.,4 0�,..,,q fs+ 41zs3
We, the undersigned purchasers of the above referenced
property do hereby request that the patio structure, as
it -is normally constructed by the builder Century Homes,
be deleted due to other plans, which we have made for a
patio cover.
We.understand and agree that it will be our responsibility
as a homeowner to provide for shading of the windows over
which the patio cover is drawn.0ur pool and patio plans do,
however,make the builder and city approved plans unworkable
for our home.
APPROVE NNING & DEVELOPMENT DEPARTMENT
6Y UATE
EXHIBIT
CASE ism. r •-
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