9711-092 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c14 WProfessionals Code, and my License is in full force and effect.
-' fh License # Lic. Class Exp. Date
I- ` 677 8 '�� 7131199
rZ
oZ r-- Date /-) 3 j Signature of Contractor ' 1`
I- O� /
U C) OWNER -BUILDER D CL`ARATION /
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ N License Law for the following reason:
Z_ ( ) 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).
LID () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
rn
Z
WORKER'S COMPENSATION DECLARATION
C) (X:
I hereby affirm under penalty of perjury one of the following declarations:
Lo F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !�= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
J (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 ation laws of California, and agree that if I should become
,. subject to the workers' compensation prov sioris of' ectio13700 of the Labor
Code, II/shall 'or
with comply with those provisions .
Date: L �' Applicant
l./
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 representativesofthis City to enter upon
the above-mentioned propertylfor inspection purposes
Signature (Owner/Agent) /-Date f
BUILDING PERMIT PERMIT# CONTROL#
9711-"l
DATE VALUATION 31"1_" LOT TRACT 20
JOB SITE
ADDRESS 72-M C. LW WAY
APN X4104"
OWNER
CONTRACTOR / DESIGNER / ENGINEER
T D pt. ?sERT L.)F%rFI oPti11:NT
SPARKS CT)NIMI 1(MON
P.O. BOX t 7ki
%"921)5 R1tNCHC) L.A. Q(1INTA DR.
LA (}1,1INTA t'A 07"5i
(,A (,X IINIA (_'A 9125A
170)771.1441 ('Rt,* 29%
USE OF PERMIT
lire
1
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L,Mt Ixx.)L. AIP1' (.'RhU1T t)h' 5:1.9 y� PF:II l:rN�AM. I�FV. t.)k:P't'.; W.,AN
(7iE(x F'1.31 at 2.901%F(Nt 1161.►L'TL-lti!�Fs
.UST -W. i ONST6tf.11CTli+N 2. i� 1.,70 .^4.
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DEC 0 3
997 J
No"
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PLAN (:YW KFFF 1014")-4i9-318 $I93.1A
C'()N4'I'1tIW-r1jvw FFV 1014) M?-4184)tlfi It"I 940
WA-1LAN LCAL M- 1111-000-421-000 598.30
EW(:7FWAL FHE lOk-000.420.000 $167.81
Ki%MINO FEE 101-000.4194)00 $142.00
sIVOPt(i MC)TION FF* - KCRID 101 -(lift -74140) S1l1
CRA1))(N(i HT1, 101.000423.000 S311) (K)
I NFkA.VRi Kll tl7.r 1' EP ? 2 -QC)lf-dpi -:kit 1wt.1.4.1 i
ART f 1-1114.1(.' Pt. ACPS - RHSlU ?01-0()0-2.SS-000 1211.95
ART IN 14YTt) 10 to A(V`% - NFRI : I t 9t
tit,ta �T•(rrni . (•OtVtirkt I( "1"1( trl .1NIf T`1,A)v 1 '! lht-K
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LESS 11Rf. PAIL VELS
A;?1 7 0),.
FOTAI, PERMIT 1''V St U11F; NOW
55,705.72
HECtIPI
DATE
BY
E INAL2D
DATla
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
fi
Ll�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Z- 'I"'
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
„Z _
F.A.U.
Framing
_
LG
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 —
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 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
.Z
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) 12 -9117 06_1111_r
COMMENTS:
LC