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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
li N{tl 1
3
Date r Signature of Contractor "'•� .r' '
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 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. '
(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,1he Labor
Code, 1, hall.fort}?wit comply with those provisions. /
Date: _ I �? ! r Applicant _ U
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 f, this City to enter upon
the above-mentioned property for inspection` purposes.
Signature (Owner/Agent) t i Date
PERMIT # CONTROL #
BUILDING PERMIT 9,111-f!+I11111
^^
DATE VALUATION �c i �►tF. fttil �i�F LOT 17 TRACT
JOB SITE
ADDRESS 784.0 C ;iRRI•i.l) WAV
APN IiA1�� ±�>I%
OWNER
CONTRACTOR/DESIGNER/ENGINEER
't'1'1 1'+�:4•�•t>'1'lll:\II:fI�h (1. At•t•
i•.J, ♦ • .1..•l 1J 1.•Y1�1.♦ t Ilb..t.l
'Z A1iy"YTiT('rtl�('1?,f
1. }11 ♦� U{ lJl-
P.O. BOX 1 716
79295 "NCI 10 Let QUINTA DR.
LA QUINTA CA, 922S0
LA (?UINVA (:A 92253
('7601771.1941 (;131,x3 2!V()
USE OF PERMIT
LOT 17, I lit\'RAZA f'1,AN 2 - PERNtt t H46LUOR BLOCK WALLS
Irk }Y(;AA.- AIPP (,'RFJ)1'1' t}H .V�'h.02 M -K C(:IMMt. 1)1iY, t)LP'I'.; III.ANAID
t�Ifti<;i+ FL"t; ftr 2r4f !_+R Rd1.ft.T1-F 'i[ Ui< i
DEC
Q 3 1997
W3TO&I CONN -1 i RU(w "I VO I '2,2 5.00 5)l
(ICKC"itfl'Nrio 115.00 SI.,
0AKAi3FJ A2(I-'t: RT iSS.(n) -,;; CITY OF
QUNTA
.j
Ess.:►.'l:1IAT D COST O f.Y)N-l't'[t:t?;>;'' 101
���,S1Ji.lii4
�g pyx {••� ,fit i* ,y
P1,ANC11I-'N 17 W. 101 -OW -+339-318 31u891
C'QNS'FR t 7( I'ff1N f 1 10 t •(mn-+i f I;-{}{1 T,458.06
ilR.rIIA141CAL FEE 101^t1(}0-i21^tom St 1 LY)
iJAXt rRICA#. FFE 1U!-�ttkZ�!?0 tiU(i ' 5171.1123
F LUN f31NQ ti1:7: 101AX)OU-410-000
STR(.114o, NK.)TK)N Fi•:1_ - RE311? 101.000-241-000
GRADI,40 F11: 101.000-423-000
tr,rkA `rttu+: t'iliil . i'FE 225-00-443-342 14.:449.74
ART IN PLTBI,IC F't.Al" H t - RF -1411. 701,01V-255_000 S226.02
ART tN tit fAf .IC, PI,A :S - RF;SIC '7()1-Q()(1. +5! -PW 4=1602
• I
SLI it -"fit f rAi.rCrt)1iC1.
$96,1143.,1
'['OTAt, Piflti\il'i' r~`Fi I))IjP No NV
55.88111.32
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -
Underground Ducts
Forms & Footings (Q G
Ducts
Slab Grade _fid
Return Air
Steel
Combustion Air
Roof Deck 7_
Exhaust Fans
O.K. to Wrap e- A< CLe-
F.A.U.
Framing f/ G/
Compressor
Insulation Q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior LathG-
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
O.K. for Finish Plaster
Sewer Lateral
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 Voftage Wiring
Futures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)