9711-096 (SFD)H
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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
Date { a !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:
( ) 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.
(X 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.
T�i3l�; i; i'P4 1`11109597
(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, ani gree that if I should become
subject to the workers' compensation pro` islons of Section 3700 of the Labor
Code, I sllallr-foAwith comply withjthbse pr rvvisions�
Date: 1 Xf X11 Applicant I j
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 Ouinta, 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 propertyforiinspection purpt
.
A
Signature (Owner/Agent)' ry Date''
BUILDING PERMIT* PERM'9 °°NTR°`"
9711 _096
DATE VALUATION' S�. R 1 0 LOT 1 TRACT _ 6 I; ,
A�
Imo«.
JOB SITE„
ADDRESS 7s-870CA%t3tMUDWAV
APN
13
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'1'.11 (Ji:VURT ININ it,C7T''tMI.N1 i
:;PtLRKS C:)NS'3'4t.tK:•I ON
P.O. WX 171d
79295 Re%NCHO LA. QU#N.4'A 02.
(.A. Q[A. rA CA. 4'251
LA (XI)1+!'.1'A CA 92253
(764►771-1941 V96
USE OF PERMIT
Is
LOT 13, ;tl;,ttRoaA .%LAX !-f'l:1��10� l:.1`7 d15.? Atl i! ! t l UL E iS C`Wti WAL1,
t)ES. P(X)L. A111' K"it,l iA1 OF $�t:1.9g:I�F: t,;tJifai4, f�F'V. i t}i�"`ti 1''1.r�►t�i
PAID
DEC 03 1997
L?t5.ttt1L.#yAT3� 4.7t).titf S#� a
GA1z AOWCARPc RIF • 0” Nil 31, CITY0FIAOUNTA
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ire T'f `1` 'A♦♦ ,yr 1 1 '1-iA'�AI 90 !T' •0 ,�
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PO.tiN CHECK 1',1 1~ 101 -0004.N -31f,
rO'N'.'TO2it(,T[1WiC rf'E,1f11-OJR(?�rliR-000 s�34Q 50
1.II;Cf4RiZ71Ce1f. i C 1 t01. 0(10«;^!-(:i1(; S?�Iq.NJ
F1,ECi'RICAL VE 11 101-600426-000 5147.81
1%1:M411INQ 193 1014M-41 4i 4-000 S#4.2.Cff)
«iIVONi'O 7Nf3'CION Fl -"U - Itrt'St?3 101-000-241-1100 S18, 6
QRAD INC' F.Mr, 101-W-121-000 :2000
191TRs SMUCTUTRE GO; 225-00" 13-342
ART 3N PLg3L1C-.KA1,3 S - kli!il , 701-11(, -25"- 00
fiW? (thi t>! IRi,Tf; PLACES _ i SWC 7014910-255-01M)
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$519�±hry.67
f .:!T_)T'k1,,(,'0N<TR r-',,V1ON. AINt(DP1,�jt1N(:i4i`E:tfky'.FEES
. LESS 1'1.3.5 -1 AID 421,39N
'If'6a'1'r f, i' ;:FtOM!'r;' ?r"#sl+ S DUk+,''%�1�1j . • 5,70S.i2
RECEIPT
DATE
BY
D TFI ALED
g
INSPECTOR
�ED
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
Exhaust Fans
O.K. to Wrap
—L , , li
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
,10N
Drywall - Int. Lath
C
Final
Final Z —
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
Gas Piping
PLUMBING APPROVALS
Gas rest
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
r
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: