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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
037252 13 0 212 9i'l Cli
Date / - 6 - 00 Signature of Contractor A�
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
perforpance of the work for which this permit is issued.
(P� 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.
ROYAL 41"N"S". (�O. 016" -,,5r,1,,=7
(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
Code, I11rhLag1,ortb8h comply with tho
Da Applicant—
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 frorq 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 property for irispection ses.
Signature (Owner/Aplent) bate
BUILDING PERMIT PERMIT#
9107-314
D,VFL 000VALUATI11 LOT TRACT
WIN 0 6 2
JOB SITE
ADDRESS 79-683 CA.SSIA STREC3'
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
C A rr.,
At �J" HS. %,,& , -.*I&.%-
I IDENMA.'"C'
A
1 PARK MAZA SNE 400
5 PARK PLAZA, SUITE 400
IRVINE CA 92f) 14
IRVINE' CA 92604
507.2
USE OF PERMIT
-�ald - L�51 3 T10vK 2 PET<Mi1'FK)F_,S NOT INCLUDE BU�CK WALL OR
t!L#.*%N Cf4fXK tUA)0C1'1QH APP1,10) IrUR
A -CT CONST RWT IONA %;,14.00
FACIRCIV-PAITO I Z.60
0AKA(M/CAk11f.')XT 48i.w SF
=WV*,1A`1rEZ MST OF", )NISTIZIR"ZIGN
114,"104
PEkM17% FFESUMMARY
S 6 9,21. 0 (1
P1, AN CI 1V r, 9 FV,,T-, 11) 1 4W- AN -3 I R S141 1A
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iLCa r A V ft 3
uu�,.c AA, JTr 101 -0110 -419,11 -fa
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1 - 1. 1: C"t R 1 e. A 1. FE E. 1 .060-420-"
PLUNIIIIINQ FEh' 10141100_41�Lo()() 3 1540)
XrQ0N(; V10TION[ FM RFS -In )AI -W -241 -MO $11 -in
G R. N i) A, Nk,; 1;
ART 1 r4 VU61AC PLAX-3 - MAD 701 -OW-253410 S -i 7.4 8
0CV1-I.4_'WFJ( JMPAC'1* FEK %7.00
ON111,z][IRUG MON
Q'I
LESS PRE. -MD ITTES
$000
TOT,A 1, 1191tMIT FFIr.-i DUE NOW
RECEIPT
DATE
BY Q_
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
I DATE -TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
46,141
Ducts
Slab Grade
-7/171 y I
Return Air
Steel
CombustionAir
Root Deck
(�2 r
Ex1austFans
O.K. to Wrap
0 - e.2
F.A.U.
Framing
19-45-100-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls z
Party Wall Insulation
Condensate Lines
Party Wall Firewall
C
E)derior I ath
F7
D 11 - Int. Lath
_eCj
!7&7
i
Final
Final
.-3 -:z
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
Gas Piping
PLUMBING APPROVALS
I
Gas Test
Electric Final
Waste Lines
_67
Heater Final
Water Piping
om_�=H�t
Plumbing Final
Plumbing Top Out
.4
Equipment Enclosure
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) I J
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)