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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 /Ezp:,Date
674074 B j 1_T N9
Date / 1 � �� ! Signature of Contractor_ _ l�
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 /
( ) I am1exemptrider Section B&P.C: for this reason A J
Date ` A' Signature of Owner''ijl /I' .j f 1 l
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.
21 have and will maintain workers' compensation insurance, as required by
Son 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.
pm IV UN I.,tto,0'1'
(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,,l should become
subject to the workers' compensation• provisions 'of Section 3700 of the Labor
Code, I shall forthwiT comply with those provisions.
Date: '} f �+ fry Applicant • +
t /
Warning: Failure to secure Workers' Compensatiodcoverage is unlawful and
shall subject an employer to criminal penalties agdtc`ivil 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 rereseniatives of this City to enter upon
the above-mentioned property for inspection purpb S. r
Signature (Owner/Agent] `• Date's
�.
PERMIT # CONTROL'#
BUILDING PERMIT
DATE VALUATION S1I8S,.LOT }} TRACT_26,390,
ADDRESS S'%I11 L,!'►ull,a) 4� .&Y JOB SITE
APN 446420-00.5
OWNER CONTRACTOR/DESIGNER/ENGINEER
T.1?, IMSEWF D1iV1?1,0Pkt1,NrI' C0.111S"1'1 UC1'10M,
979i RANG 10 LA i, W91A DR.
21.0. BOX 1716 ��..A
IA QUINTA i�A 92253 QU1N'1'A 0\ 022153
�7fi01771-19t1 CFTF.�f ��ici
USE OF PERMIT
SF is
LOT 2.9, Tj--JMA7.A PLrkN 1- F%C.Rhi1T DM -S NOT INULIDDii 61.0kr,
OR 1'11,(•)1.. AIP1' CRILiA T OF S21 Z 1,;11 NIi 2 i. 0MM, DEV. IVI'T.: PLAN
CM. K FhE @ 2."4 FOR mLjI. Tt-1sxLiH. iDEC 0 3 1997
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CTY O� LA1NTA
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PC )RCIIr'ATI0 170,11u; -Si"
i#A►kAfitlt;rlttl'c:,1t? 18!y tk► S!z
1'iERMI T #+F.i: SITNINIARV
PLAN 4,31EC K FEF: 101•C00-4311)-318 3I9*3.454
CONS"n?f f(3Trt")N FT -.!y 101_000.419.171)() � 1113 i(l
111sL IIAt31LAL FUM 10 1 -(= A21I.000 S'":,3c1,
1i1,,i�:11t1C 11111`. FEE1111-ow-�i"o-000 $10.NI
PLt?SIBIN0EEI; S14 11R1
}?{lT3(i iuirl'C4{7N h -i, _ Ri Clil iI-11211(11-2.11- - $ tR. V.,
QRAf INt'i 170.' 1011-000-12-3.000
IN 1tXV RUA�31JRR FIT- 225 -GW -443-342 Sri, rZ4.71
ART IN PUBLIC: PLACE, - RE`tC 701-fJ1;14)-25$-OW S21:i•��;
ART rN i'i_ifif,tt, KA0?R - Rt'uS1V 701 4W -255•(K111
St1f1M)T'A.I. CONSTRI.iC,:"I'ICM ANT.) PI.,AN C'M,(,h,
j LUSS, 11"R ?-11A.10 BBL'S -x213.35
'i YI'Ai1. E' R181?X'i' 3 KFA 011F, NOW $5.785.72
RECEIPT* �/�
DATE
BY
D FINALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
�_
Return Air
Steel
Combustion Air
Roof Deck
Z- .
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Qj
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
3_���.
Final 'Z �
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
I O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Y
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
8
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:
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