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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under, provisions of t
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
J1�jf.tt i051 IW
at
eSignature of Contraoo `
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.
( ) 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.
i'4 �p C" a %44)68��(�
t si lLf711Z,(A Zi W i.l Yl:1. ,:00
(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
Cod sh II,�. f�ta„wr comply wit�l
hose•p slons� r
�ateu�" �'r" Applicant �` s
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, indemnity
& 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 -f^or ;nspection purposes. s
/ignature (Owner/Ager�t)'�~ Date' `� t
jr
BUILDING PERMIT PERMIT# --
DATE VALUATION $147,425, t LOT F ,11 TRACT 127.909
A/.,l6, , f
JOB SI E It ' r, .
ADDRESS.�_.1.,1�:1,«3.E'�i�)Y.t..�
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APN
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
t
�y
A. t ViVI� v
1335 SO. rrV' S t'RM; S E. 12;200
1333 :s(]- "D" g 1'kE i', S Ii . 42.1111
SAN BERNARDINO CA 92409
CA/.'19(?408
/S��AN gqT3ERl(��t}A+.�RC)INO
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l gtly�yT(l1-tt(?t}7. {v�}li• �f,�l�
USE OF PERMIT
oFU, I.W # 9 (, .1K•Aji 4( BR.. PVCMIT DOES WT ,INCLUD€,1SLoc"k
WJUA LS fid. POOL..E�:LAIV
1SSt:i.ANCE OF Sr>ME, KAN TYP—TI•.
'MACT C,iW111Rs;,CrAIGN 2147.00 SF
:36.1717 Sill
AltE► sLAf .rli2!'t fi'9' 635.00 S11*
$!ni,.V.,RAIERT/1 D y.eOST tl.✓:V,I CO1''/-3111 U'1.v4•IG `{
144425."
�I�.E'lRAfiT.9t R Si13MAMAR
Cot 4TRU'C.Vh-,)NFRF, 1411-0004i1240) �t3Q7,ti0
lzt,
t.f1110kL 1'M- 3, 1!11400-4121-000
Eat: ?t°"i'1tJs, AL }41.1-1)tiC)•Q:?s2-174t� $ta%.'?
k�1 t ?,M1a1 Nt '1<C3? 10.1.061-.1-41 '19-000
i't`t?.0",%%(t'N;Rf3"110?? e FIT10 1 $!4.74
eitW'11P40 FEE I.Ui-llUG-d�.`� u?tld7 S20.0u,
.3N it.� �3 c12'Ut� l L1121i 1�t ] 5-474)ii��i43.3�12 $_v%06.3 I
.AR'i'tN 4° iBLIC PLAC FN . wLS1t.:701-iN:i(?-2,ti�.(i0t3
y
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S f11:fTT'f::1t CONIS°'1Rx,14::" K)N .A.M0 P1, AN) 1"111?C;I:
�4,Rt3fi :2l
SEP 14 1999 LESS, PRE -PAID FEES
$0.0;l
OF �G �r E N h e t
%'A 6 1{
RECEIPTDATE
:�
BY. {
DATE FINALED
INSPECTOR
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs . .
Underground Ducts
Forms & Footings t6
Ducts
Slab Grade, Q
Return Air.
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor
Insulation rzVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final /tz
BLOCKWALL APPROVAL
POOLS. -.SPAS.
steel
Set Backs
Electric Bond
Footings -
Main Drain.
Bond Beam
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
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:
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1�1FEY ;DEPARTMENT
CONDITION, LILY
ECT TO INSTALLATION AS PER
AND ALL APPLICABLE CODES
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