9604-140 (RPL)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
cvu Professionals Code, and my License is in full force and effect. ,+ it
O Z) ch License # Lic. Class Exp: Date
ir� C) 'n fi is>i7i3 i.'S 10131196
W T
� lY � - ! E h •
a
Z r Date µiv r Signature of Contractor �~
T O
Urn OWNER -BUILDER DECLARATION
wWO_ (0 1 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
contractors to construct the project (Sec. 7044, Business & Professionals
Code).i %
C'') O I am; exempt under Section , B&P.C.,for this. F l sone
N Date + "`i Signature of Owner l' .r V f J"�
ON
a)d Q WORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
Q CJSection 3700 of the Labor Code, for the performance of the work for which this
Il
LO permit is�i's`S•fued.!Apworkers' compensation insurance c4ir0f &lpolicy no. are:
,It Z Carrier Policy No.
w D
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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 I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful acid
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 representatives of this City to enter upon
the above-mentioned property for inspection purposes. -ice
Signature (Owner/Agent)! r'%fi` Date
BUILDING PERMIT � PERMIT v6°°NTR°`96044403 213
DATE 4/29/96 VALUATION $,1,5,0410) 0Q LOT TRACT
JOB SITE49-Z.'(? PASO `li'[1 A41"O
APN 646_3604106
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
11 f.fris A j/LA a�I.:L. '
CALIFORNIA x'001,$ & PAS
48225 PASC)`1'Irt11f't71.,N
41910.1.30KRDWAI. k. 91V
LA C,?U;NTA, CA, 92'51
PALM 01:SETC1' CA, 92760
1;619)340••!'11110 CW10 355
USE OF PERMIT
P00 , A.Nt.VOR, SPA.
3' .NJ .YAlb .,7Jidt }'L'H l:�,lit rll 1)4! Y�3
WSi'IJUA,1110 COST OF CONISTIR(YU ION
I.S,IDUti.13t!
111`4' '4+z1+; Sl1fVlls?IAItlr.
FRAM C, HFI; l�.1 EX 1.01 -NO -439 -MR 310530
CyjNSTKU'�7i`10N FEE, 101-000-418-000 5162.01)
X19CeUAT41CAL 1, 41, — t'CfOL 10 1 _000-11'? 1-000 3211.011
14,1 C. TRIC: At. VER, -- IK)01;, 101-000.4204O1K) 3 tS:t31!
Pt:'1.908) NG FEE, .t P00t, 101-(1011-41'9-000 32`1.1113
CrJPiS":muc"fioN tkNr FI,,m\1 CR C'1c.
$363.30
LESS ME FEES
$0.001
'xlll, PV, IT F1<,EIS. 1)JV1, NOW
$363.30
.RA4,I
RECEIPT
DATE
BY if
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
k -✓-1 (t 2 -
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)