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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
' 11in""2 i 12131./411)
,�a� r Signature of Contracto���/ yl .
l ._ rn.
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.
()6 1 have and will maintain workers' compensation insurance, as required by
S c ion 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.
SI TK:'i FtjND 626354.97
(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
dde, I shall f Ahwith comply wijh those provisions.!
ate:
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.I
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 of this City to enter upon
the above-mentioned property for inspection purposes.
/ignature (Owner/Agent),+ s ,J� 1 -9T �- Dat '/r���"j 'J
BUILDING PERMIT PERMIT9XIA-169 CONTROL#
DATE VALUATION g'111�i.ftf.; LOT 27 TRACT '71694
/ r
ADDRESS , -654 COO �.OUriI
/�t .M
U -654
APN
609-;;180,013
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1111' EXCHAA:G,; CftfOI f'
t"o Wilt SINES.-LENMERM A:;ri C.
M-61 ? NAit LE'S D.R.
78615 NAPLES DIU E
LA. QUINTA CA 32753
LA QU1.NTA CA 92253
(76Q)77;-0222 01101 185.4
USE OF PERMIT
8RD
SP17 LOQ' 27, t'LAN 2AR. PERA4IT DOES NOT INCLIA)E :BLOCK tiJV,LS
Olt 110OL, PLANS HECK FET, REOUCO) f4Y i5% F OR IULTINLE:
['93VANC7F OF SAME; PLA7N'rYPE.
TRACT JV.. n.U,—.No.l4
PCiRCtVPAl 1'10 76.09 SF
ttrtil2ActF:fCA1t t 1R'r 40.00 !IF
E'.S.1 i11ATED COS a IAF C:ONKFRUC ION"
108.613140
6'EAC f F ;K SIUNINIlAR
C ONSIVRIX-710N [:YE:E 101.00() 4114-019) S671.it�
f'f,A'1401iT�, VP tI2W.K6
f1�C'blrl.'m1tC;r` 2'Ghs 101.Off0-1421.000 i;`ti}
NX -f- i7t1.t: AL VEZ- M-000-420-000
Pl,t.iWINQ EE10l-000-419-000 5134.75
CT(tONrl440111`'f34 }f)1.(}(t{y-241-000 $10.86
(JRrtT)ING I;Ef; 1.01-1400•423.000 S20.06
JNT,RAS"1'1W CTtJ! E FqE 225 -OW -K-01-42 S2,r121.06
Alar IN PU131.1C'PLM'S - R11SW 701-00U-2135-000 324.5:4
SUR-Tt'�'TA!,(2I'.)N�"1'R TC*n0'N AND MANC'i�►�C:K
MSS FEES
53,588.0'3
;n.XE-PAID
pa�%D
$0.00
'l�MAL1PER4`��1"1��+�:r,:,1)I)i�:l\`t1W
*3,585.,9.3MAY
41998
0 :,
CEIPT
pe,
DATE
BY,/
DATE FINALED
INSPECTOR
f�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade
fo -Z -
Return Air
Steel
Combustion Air
Roof Deck
O.K to Wrap
Exhaust Fans
F.A.U.
Framing
— Q—Q
Compressor
Insulation
_
- -Q -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
22
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer lateral
Pool Cover
Sewer Connection
- Z- 'F9,
Encapsulation
Gas Piping
Gas Test
_
Zl
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
t..
Final
Utility Notice (Perm) 77
COMMENTS: