9609-005 (MISC)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
Date Signature of Contractor
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
Signature of Owner / 1,,.,
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.
( ) 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:
Cartier Policy No.
(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, I shall forthwith comply with those provisions.
Date: 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 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 propert for inspection purpo •es
'Signature (Owner/Agent) /ir%� !/' Date 9^ !/
BPERMIT# CONTROL#
BUILDING PERMIT3927
160941105 3 9 2 7
DATE 914 f VALUATION $�{ LOT' TRACT
JOB SITE
APN
ADDRESS 78-555 &%,G J"0
646-31S-005
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DON C At NA11CY W;1..I ELM
OWNT R-81JILDER.
LA. QUIN'i A CA 9'1?53
(( uu
`� 13}: #
USE OF PERMIT
M S('ELLANEOUS
AC`11VA1'H PERAi T # 13426
51`'13 7MY - 6 F1' '4114r-0 r- WAM/
W) P001.
fe_ST1MA`1` D COST OF COJNS710JC."T10N
0.00
1':E RM9.'1' F CC SUMMARY
SPECIAL INSPEK.� 1110N 101-000423-000 S100.00
CO
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O
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a �
LL!
V)
SUti-'IiJI 1., CON19ITLUCTION AND MAIN CHECK
5too,00
LESS PREPAID FEES
$0.00
TOTAL PER3MI[T FEES DVE NOW .
$100.00
RECEIPT
DATE
BY M _ _ 17
DATE FINALED
INSPECTOR
i
QI
cvw
INSPECTION RECORD
,or
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Root Deck
Exhaust Fans
OX 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 g 6
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
Appliances
Final
COMMENTS:
��F�A�'�-��� Ami
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)
11:
September 25, 1996
Mr. Don Wilhelm
16 Taylor
Palm Desert, Ca. 92253
Re: Special Inspection Permit # 9609-005
Dear Mr. Wilhelm:
Please accept this letter to clarify the Special Inspection Permit # 9609-005 issued to you for the
project located at 78-555 Saguaro.
The Building and Safety Division has issued this permit to you for the express purpose of
completing the above mentioned project without requiring a complete set of new submittal
documents. The intent of the permit was to provide a vehicle complete the remaining inspections
within a timely manner, but not to extend the already expired permit for an additional one hundred
and eighty days.
Please be advised that we need for you to complete the project no later than thirty days of this
correspondence,'which is October 25, 1996. Should you be unable to do this we will at that time
begin the abatement process through the City's Code Compliance Division and City Attorney's
Office. To obtain an additional permit at that time, new submittal documents and fees would then
be required.
Please do not hesitate to contact me should you have any questions as we look forward to
resolving this issue.
Sincerely,
Mark Harold
Building and Safety Manager