9705-154 (RPL)Y_
* 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).
X� I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
�ode).
() I am ex mpt under Section B&P.0 or this reason
V Date w'7_7 el 1 Signature of Owner I 1`` 64 44
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:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(iQ2 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
Eitbject to the workers,' -compensation. provisions of Section 3700 of the Labor
(code, I shall forthwith comply with those provisions.
Date: "i 2 r� ti `7 Applicant f.}
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.
t
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 propertfy, for inspection purposes.
Signature (Owner/Agent) jll �t�P �-�. Date tiff ` fI i
�.
If
BUILDING PERMIT PERMIT# CONTROL#
9705-.04 15243
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 78-735 SAN ITA DRIVE
:604-171-111)2
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C.MtY 17 LEE
MWER / BUILDER
79733 SAhiITA DR
LA QIJI V'TA. CA 92--153
rail#
USE OF PERMIT
P( CA,
POOL. SPA ONLY'
POOL ANI:J,ti: R ."SPA 4000 -00 LS
FUSTIMNrly,irt COST OF COM01RUCTION
MAMBO
PLAIN C1010K 1-%A 101-000-439-31k
CONS'4'A IX-7't(N Fig" 1011-f,1tO-41MOO $11x.00
MEC RA.td1CA1.101- POOL 101-000-421-000 $s�1.0tJ
�..lic�'C1t1C.:AT..i�.i -- Pcx°1I�, ji►i-CH1ff-�S�t1-1}tif'1 �iS.Oti
I'1.OMBING FEE -- P00L 101-000-419-000
9
PA D
LESS PRE-PAID.7 PE s
50.0() :.:
JUN 0.2 1997
TOT PFIR1!' IT 1!'ll±.i.N tlt'lP,?. iNOW
CITY 0AFF LA QUIWA i
RECEIPT
DATE
BV
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
Party Wail 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
pment Location
Under rou
Underground PI . Test
Final
prig
PLUMBING APPROVALS
Gas Test
ina
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: o
c4Ii rzt> 3 3 0 - 1 p / TF ns ael-6 OepEQ6 4b
-FL.
c} o00
0 0
CITY OF LA QUITN A
BUILDING &,:%)AFETY DEPARTMENT
C> I- CONDITIONALLY
ACCEPTEC FOR CONSTRUCTION
SUI 3J ECT TC 14NSTALLATION AS PER
AND ALL APPLICABLE CODES
k LA Yy',e yy
p I, (fir
4. V.
76-755
Poo
4-A!
,'ONTRACTOR CA -Ey
)WNER CAV,< LZS
CITY OF LAQVINTA
SUB-11AT
.�. . -1
ADDRESS...
JOB I ADbktss
1115 OV1111 *11011 gilu WLPOLICLA Vill Logo jy"-VVILKI unw-laullulliv
t is the responsibility of the General.Contractor'or the Q*yvn'eo'rlBuilider*to,,,,mc)nit 'or' the sub -contractors that
ire on this list are the same persons perfor"min'g, the work. Any - changes-, to this list Must be approved the
'ity of La Quinta Department of .Building, & Safety gd!Qc . to, work a changed sub -
7
a -work arid/or the voidance of building permit.
,ontractor. Failure to comply will result'in a stoppage of
CrT.Y1
SU+B':;CdONTRA-CTGR.!.
TYPE
STAT
BUSINESS...'.....
'TRADE
NA
i�. LICENSE'.***.
CONTRACTOR'SCOMP:
NAME/
LICENSE::
LICENSE
NUMBER ON FIiE:NUMBER1
. .
...........
NU BER""
4X
GR
:Ab'v.
6 -bay
LJFI*-
A/C -12
EXCAVATE::",
PIPELINES'::;;.
C-34
CGNCRETW'.
LAY "ey
L..F
C-8
FOUNDATIONS:
ASPHALT .,
A
FRAMING:%
B
EEL[.
O
IZ&7-0
C-51
s73g4t3Ex,
STRUCTURAL
MASONRY
C-29
PLUMBING:..:
Zo
C-36
LATHING::.:
C-26
DRYWALL�.:.
C-9
PLASTERING:::
:FbA:Iy
fo*L 60,;cT.
C-36
('66 4-A
-Tit2843
45
HVAC*
C-20
-.ELECTRICAL.:::-:.::.:::.:
A-ZV
p0_L_e_
C-10
573448
ExramFr
(General) :>
ROOFING:.::C-36
SHEET METAL:..—
C7.43
FLOORINQ..
C-15
GLASSI.
C-17
GLAZING- ...
INSULATION..
C-2
SEWAGE DISP.*.
C-42
PAINTING]:
C-33
DECORATING
TILE
L -b4
CABINETS/
C-6
,INSTALLATION
FENCING
C-13
LANDSCAPING
C-27
POOLS
C-53
OTHER
L
Mb,-WC:AL
C -W
472:67,
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: 714 12
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