9606-041 (RPL)LICENSED CONTRACTOR DECLARATION
c I hereby affirm under penalty of perjury`that I am licensed under provisionsof
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c\I w Professionals Code, and my License is in full force and effect.
.71
O d � License # ` Lic. Class! % i Exp. Date "\
W _ (156128 � c 5l } '! � i 10j3119ti .
Z r Date' Signature of Contractor I
O "';✓
U °� OWNER -BUILDER DECLARATION
W 'W I hereby affirm under penalty of,perjury that I am exempt from the Contractor's
~ 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
j contractors to -construct the project (Sec. .7044, Business & Professionals
Code).
cY O I am'exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
OC\J
Q WORKER'S COMPENSATION DECLARATION
CL
O Q �. 1 hereby affirm under penalty -'of perjury 'one' of the following' declarations:
Lo F. -O () 1 have and will maintain a certificate of consent 10 self -insure for workers'
X• W compensation, as provided for by Section 3700 of the Labor. Code, for, the
DO _J. Q performance of the work for which this permit is issued.
< U (r,,,).>P have and will maintain workers' compensation insurance, as required by
p U Q Section 3700 of the Labor Code, for the performance, of the work for which this
permit is;issqe41 M.yfivyorkers' compensation insurance carr,•ierq& policy n_o. are:
? Z Carrier Policy No.
ob. Z)
r\, d
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 laws of California,,and agree,,that if fl,should become
M
X �
subject to the workers' compensation pr ovisionswof`Section 3700 of the Labor
Code, I shall forthwith comply with tth"�o^se,proviisiionss.{
J J�y.Ad!f F..b. 'fi .».4'.Y -P. Iy .✓•Y-f...•:IFa �.�.......-.--
Date: Applicant =r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
-addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code,. interest and attorney's•fees.
IMPORTANT Application is hereby made to the Director of Building and Safety.
for a permit subject to the conditions and restrictions set forth ,on his.
application.
1. Each person upon whose behalf this application•is made'&•each person at
whose request and for whose benefit work is performed under.or pursuant to
any permit issued as a result of this applicaton agrees to, & shall; indemnify
& hold harmless the City of La Quinfa, its officers, agents and 'employees.
2. -Any permit issued as a result of this application becomes null`and void if
work is not commenced within 180 days from date of issuance :of such
permit, or cessation of work for 180; days will subject permit to cancellation.
I certify that I have read this application and state that the above in is
• correct. I agree to comply with all City land State laws:relating to the building
construction, and hereby authorize r4presentatives�of this City to enter upon
the above-mentioned 'property/for inspection purrp9ses.
. �f t�,.,.'� E }'_- ✓ F., _ ,I"
Signature (Owner/Agent) V l Date ��
..Y
i g BUILDING PERMIT : PERMIT# CONTROLJi
>� 34751'
DATE , VALUATION LOT' TRACT'' _
-12 s
:JOB SITE
APN
ADDRESS 48-285 :IFsk1SO •')1 I!EA00
r
OWNER r
CONTRACTOR/DESIGNER/ENGINEER
LI2:�d 1"A$O II Ivimy
4:1910 60APLaw:r;_ A i#
1A. Qf,11N70t►
1.ALM I.71:S:P:RT C.A 92:260
019)340000.0 3,5,5
USE OF PERMIT
I100.I...AN.lJ OR SPJ\.
t.N_iOL AW :SPA. OILY
vt:�t L ►tstMA SPA _ t0„000,00 L9
ES�li'TiM. TED COST OF CONSTRUCTION'
PLAN CHECK PEE -.101.-400-43931 K I7C,0S
CONSTRUCTION FEC 101-000-418000'$ i 11.00
&H-33 "!#NNICrA.i. PPE u 'POC . 1W40 -1121-000 $24.00
In,.W1'.RI.0Al. lrl~i'i—.PC'01.. iot-000-4;1.0-ow $45-00
,
PLUMBING I:`:Sfl, -'LK)01,. ' ' : 101-00.0 419-0) $27.00
wXe
..'y'�
. � 4
. • A 1' /�'/' p,[(',�p ( y��� y4 r (� yv
a Gi ANDPLAN
SUB -TOTAL 1'lL lsl�N�,7 i•ROO- ION 11l'i tJr�Piia,.."lP.l}�Fy4f-✓.1.`t�L:`�,� K
Q {,.(.1�•�y1.1.,
. 289.'.�11 , • '
C q•
LESS l�.kE.-I.�s� ID V ''R S
$0.00
)TLPEANUT FEES OUR NOW.
smos
JUIN 1:12 1996-
J'.
1y
�1I
'
RECEIPT
DATE
BY
DATE FINALED•
INSPECTOR
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Patty 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 PI . 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
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: