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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
B
ate -J 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:
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 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.
2EN1111IN&
(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
C,Ode, I shall forthwith comply with those provisio I ns.
Owe: Applicant_
Warning: Failure to secure Workers' Compensation 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 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 (Own r/Aa nfi A Date A 5�;7
PERMIT# -CONTROL#
BUILDING PERMIT 9612-121
5 8
DATE 11,9/97 VALUATION S 145. 10.60 LOT 74 TRACT 2,4
JOB SITE 79-205 Ck"int 0 IqUtSADA
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
R A NN C3 101 '1 ) C Of ! I 1 0 '1. P
CIPM11URY CKIIIATIA.
1535 so. 1V SITREE-i" �;re, #200
1,513 SA). -D" 91REXI', #2100
SAN WIRNARIANO CA 92408
SAN 10,1174ARDIN0 C.A. 92408
("9)381 4W CRL# 211910
USE OF PERMIT
"NO10 000TiLL0 - PLAN 4Aft
PLAN CHU.'Ck FEES.It UI)LICED BY 75'�-* FOR MULT tPLE WVES (IF'rHIIN
TRACT COINSTRUCTION 2,4X00 SF
t10RC1VPXM) !�6.ik Sr
190.00 3F
1VS11MXfXD CMT Of' CONSTRUC110N
1.
PERMIT 1411H, SUNIMNIty
NK Ve, 0 N V WE lot -000-08-000 sw)(11.50
VILAN UI I ft(Y' 'VP 1? 1014"1-439-119 5 167, () I
A110 -NI ANIC ALTTE.S' 1101-000-1121400 U5.10
ELEICVRIC Al. AIRS 01. 5 6
IPL�rNbilfltl I;' 0!�S 101-000-41.9-000
!01-1011-241-10) $114 54
22:-MO—i41-342
AXI'IN PI,A_C'F 1411 (RES) 701-000-25540) v 1179
'SU849r.Ab CON.4UC-BON AND PIAN CHECK
LE
PAID..
TOTAUVERN111' FEES DITE NOW*
JAN, 0 9 1997
OE LXQUINTA Ln)
CITY
RECEIPT
DATE
DATE FINA LED ____7PPECTOR
7BY
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION_____T
DATE _F
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/ / -
Underground Ducts
Forms & Footings
11-01101-7 Z.
Ducts
Slab Grade
4 X,
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
- Y Ad, 17
Final
Final Z4 1�21` 17 ( -9,
BLOCKWALLAPPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I I
Underground PIbg. Test
Final
I I
Gas Piping
PLUMBING A
,PPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Somer,Lateral
Pool Cover
,s,?,onnection
CseymEncapsulation
Gas Piping
Gas Test
Appliances
Final
Final
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltne Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Litildy Notice (Perm)
COMMENTS: