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LICENSED CONTRACTOR DECLARATION
I helleby 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
/"I USK i
Date A Signature of Contractor X-41
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.
SeC`I have and will maintain workers' compensation insurance, as required by
ion 3700 of the Labor Code, for the performance of the work fo� which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
.711-417111. Kl.'i. (A).
(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
Rode, I shall forthwith comply with.tKose provi�ions.
V'Date: Zl' 2— L Z Applicant ,ZrI�-'-
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 Persoh 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
Zthe Above mentioned property for inspection purposes.
ature-(Owner/Agent) Date
PERMIT # CONTROL#
BUILDING PERMIT
V10 2- 126 8 5
DATE VALUATION IS111 RACT
119/97 ,S6.4QJ) LOT' 71 T
JOB SITE
ADDRESS 79-235 GWONO ROSADA
APN
604-191401111
OWNER
CONTRACTOR / DESIGNER ENGINEER
" 11 , I -
NAKC,3101 011YT1,11111110 111P
'My ('IV
C E I'M" 0 VY E I I L C 0 MIM
i_;35 scy, 91'E. #21,00
1535 SO. "D- KIRE01', Sll,!. 1121YO
"'Al I
4 ttERNARDINO CA 02409
SAN HERNARDINo CA W408
USE OF PERMIT
RANCA10 0Q,01ILL0 - PLAN 2XA
TR A C" 11' C'0 t, I[3t I R U (110 N 1.907-00 S11,
14003VI'ATIQ 55.00 SF
0A1ZA0E/CXKP0RT IF
PgRAUT."TU MIMMARV
C ONSTRUCTION.MX3 101 -000-4 1 R-000
R11AN rKtFCK Flip", 10 1-004-419-2119 $5*79,0
W."CHANNICAL FFES S S-1 S 0
-420-OW
I -ILUMM
- No 1q3ES
vmwo mo,rv-mN 101-000-241-000
ORADING 101-0W,423-000 $20.00
iNF11ASTUCTOW3 225-000-443-3Q $2-59(151
AK'1fNf1kJA1.JC' PLACES' tpEs.) .701-000-25.5-M
I 9701�AT CON-STRUCITIONAND f"LAN CHECK
4S4,2,65,26
P LESS PRX-PAID FEES
$O.00
TM ALYERMIX FEEN DUR, NOW'
S4,265.26
ul
[RECEIPT
DATE
BY
FINALED
INSPECTOR _71
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I
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
,7_4
Final
Final
BLOCKWALL APPROV.41LS
POOLS -SPAS
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 /ROVALS
,/PP
Gas Test
Electric Final
Waste Lines
Heater Final
_(z
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
,lateral
Pool Cover
_7Se—wer 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: