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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury'that I am licensed under provisions of
j -Chapter 9 (commencing with Section 7bOO) of Division 3 of the Businessand
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
i JIM 103 1 i97
Z.,Date ignature 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 Si gnature 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,Q 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 ZETA'TLU. INS, CO. Policy No. ")W.,,01600 t
(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
.e i those provisi6ns.
,,Pocle, I shall forthwith comply Witt
V Date: /- � ^ �' "' 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 informatign is
correct. I agree to comply with all City, and State laws relating to the buil6ing
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
V/Signature (Owner/Agent),.- Date/
PERMIT#. CONTROL#
BUILDING PERMIT 9611-134 1 .. 44593
DATE 119/97 VALUATION LOT TRACT '24517
JOB SITE 79-230 CANON0 140SAIM
ADDRESS -7
N� 604-192-007
OWNER
CONTRACTOR DESIGNER / ENGINEER
Il
v:�, at a v yzamt.i t—, c r.") Nm, j y �j r1ri t, cc
1515 SG� 11Y� 9rK,r_`VT' 9116. 61100
15-15 so. no:, .saRL-an" noo
SAN WIRNARIANO CA 92408
SAN BERNARDINO CA 1424OR
C11110 2420
USE OF PERMIT
RANCt f0 OC,01 I t,60 - PLAN .1 XJN�
PLAN' (" HHUX VERS IkFIA i(XI.) 0V
TRACIF CONSTMUC11ION 1,804.00 SF
WIN) SF
ES`1FV%1AT1'U) COSTOP" COT-11-STRIVU810IN
PR"1111' FEE' SIAWMARV
CONSTRUCtRYN Flit: 011 -WO -419-000 $674.50"
pf, AN 01 JIICK PEI, 101-owJ39-119 $141.29
N1113101ANICAL 17-M-8 101-000-42f-000 160,00
uj]-Wo420-000
RLUNVING F'FESI 1.01-000-419-000 $148.19)
STRONG N40T 10N
INFRASTUCTORE 225-000-443-342 S,�,467.31
Wr IN POOLIC PLAC'E-S (,FWS) 701 -ON -255-000'
oUrl IT -YEA!, CONSTRUC110N ANDWAIN CIJECK
LESS PKEWIAID'RIIES
SOM
TOTAL PE"RMIT FERS �Dif K'NOW
*0 JJN1
Of- tN
RECEIPT
DATE
6Y
FINALED
INSPECTOR
�W�-
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
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 ln� 421"7 1 (Z
POOLS -SPAS
'
BLOCKWALL APkOVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING A
,PP,ROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sho
,Wff_P a n s
O.K. for Finish Plaster
9flieL.IAteral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 9ZACY7
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
Utility Notice (Perm)