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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
101-11 A7
ate Signature of Contractor
W -
OWNER -BUILDER DECLARATION
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 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 cons6nt to self -insure for worke.rs'
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
Sec ion 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.
ZE11411rif 1NIS. CO.
(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 3700 of the Labor
C4e ' I shall forthwith comply with tjhois�e provisions.
Vi5ate: Applicant
Warning: Failure to secure Workers' Compensatio n 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 3766
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 property for inspection purposes.
Zignature (Owner/Aaent) Date
PERMIT# CONTROL#
BUILDING PERMIT 588
DATE It 9P)7 VALUATION LOT 76 TRACT
JOB SITE
ADDRESS 79-145 CAMINO ROSADA
APN
( )04-191-0"
OWNER
CONTRACTOR DESIGNER ENGINEER
RANC 110, (];COTILL0 1,11 -
CROWELL (:Ommtuj�unr,,�
1535SO."J)" V'REVI', STE. 5200
1535 SO. T" STRPET, 911F. fi200
SAN RURNARWINO CA 92408
SAN BERNARDINO CA 02408
v -1-007 CB11# IIIII-10
USE OF PERMIT
SIT)
k1kNei 10 0C,01 [U.0 - Pl.AN 2K 011
�PIAN ('11MYCK. l7lih'S REDUC11D f4V750/* FOR MULTIPIX ISSMS OF111-13
P0,RCHAW00 M,
0A1tAG8t(1`AAI1'10RT 8F
%0. 7.
!ESUNIATEDC STOPCONSTRIX 10IN
PERMIT VEC.SkAA MARV
10) -OW-418-M)
0 4VN (If 4_11.709. 1`1*91 1111114"419-318
Coin,
1,01-000-120,O)o $1,27,iif?
101-000-4191-000 S 14S, 00
till , 11),ONO k -10130N 00"g)
I NI -A W;f* JU11 00. 225-000-441-342 1213�fi).Sj
70141100-V-5-000 114 66
PAIDYrAIXONSTRUCTION AND PLAN.04ECK.
$3.0) 68
LESS PRE -PAID FEES
$0.00
JAN 0 9 1997 ,cm,'o-gyma
$3,8.yo.68
CITY OFIXQUINTA
9 ECEIPT
DATE
BYt-\
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION _F
DATE
INSPECTOR
OPERATION
DATE _F
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 4
Ducts
Slab Grade Z.A 4�g,2
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing 1, 417
Compressor
Insulation 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Unes
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
UndeTround Plbg. Test
Final I
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
4��rteral &�F/f 47 4(�
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 X
Utility Notice (Perm)