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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. Date68601951 RAI 1 ;1 ,,�r�J�0p2
.' ^�
Date i - ?' �� j Signature of Contractor - - ,
77
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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,
Section3700 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).
( ) 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- eco on 3700 of the Labor
Code, I shall forthwith comply with those,prod-inioIns.
Date: r t `; r f 1 Applicant—
Warning:
pplicant Warning: Failure to secure Workers"Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and , restrictions set forth ori'•. hi§
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all,City, and State laws relating to the building
construction, and hereby authorize representatives of this City to.enter upon
the above-mentioned property, for�,inspection purposes.
�^ Signature (Owner/Agent)`- Y/ '") &NA ►' l Date — f�' "N
/ BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01W400 TRACT
t12 .7!Z Q dl
JOB SITE
APN
ADDRESS
79-040 01MUS a
76-9.7:2"Al. 7
OWNER
CONTRACTOR DEN INEER
MMAD 31.0 s
7M."'! ! RWW-$
CA 97.5016
SIDERMY. CA 92.5 06
�t�f�552 L~E1E 5386
USE OF PERMIT
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,J`f��V S✓P"IN 7 RAL AP LV14 UA +] i E °Y 5
SM, LOT 64 f:BLAN IH'- iPER:MT DOLS, 11M IN"CILUD.F. BLOCK W.1%1,1, .
POOL Y1R1:+WY MA Y APPROACH.
CUO"I'OM COAK)MU6TIM ?,762.00 F
PORCY-Il`fa.A VC11. xf .tt0} Sty
0ARAORMARP00 (91)
9911MAUD COST OF CONSMC1101V
:112917.56.60
PRIPAWFER SUMMARY
CONYTRUMION FEE 3,01-000-08-01,W) S1,09i'm
PLAN CHIVI IK FEE 101-000-439-318 $8946,69
MIt.C'k�AAiM.f LYPS 101-000.42I.0001 $0150
i3:1u1 CT'R1C. 1, P99 101.000.420-000 SI O.14
PI✓U3' BI1;PO.FFIR A 01 -000--419-000 3111-W
STRONG IAOTION 6TEE - iMID 101 -WO -241 -000 MRS
ORADI1r}•0.n- 9 101.000.42.3.000 $2ti.X0
1NTRASfiAL1• TIAP,Z Y: 225-000.443-342 a1,9t97.00
ART IN PUBLIC PLACM RE911: 701-0004,55.000 M.$e
---�E??mac ;'110MAND -11-Mi CT3Efak$4,423.L9
' 1 UUMS 1TR:F'-PAIDMS
$03.100
L E NOW
F JUN 1 5 2001
84 V
CA OF LA OUINIA
ONHr U DEPT
RECEIPT DATE ”'
BY
DATE FINALED
INSPECTOR
Q,, ,
INSPECTION RECORD s
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 `'
O.K. to Wrap
�_ �/ _ _
(/ ( `li(
Exhaust Fans
F.A.U. _
Framing
Insulation
��iGl _
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
'Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
l� V" Q r ��
(/"
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond -
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
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
ewer Lateral
ewer Connection
�� " / d—� ,
Pool Cover
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:
�I
. CIT'
BUILDINC
INSPE
�- SHEEFfIL, I
Contractor SHEFFIELL
Permit Number 0106 -
POST ON JOB IN
INSPECTOR MUST SIG
JOB ADDRESS u 79-94
SFU - LOT 66, PLA
INCLUDEBLOCK
D.IUVEWAY APP11
TYPE OF INSPECTION
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
AO NOT POUR CONCRETE U
CONCRETE SLAB
JOISTS & GIRDERS
ELECTR AL GROUND WORK
--,- 1166c./* c
DO NOT POUR CONCRETE UI
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & OAS TEST
HEATING & VENT • A/C
FIREPLACE
HOOF
BOND BEAM
U.K. TO WRAP
GROUT 0 a' ❑ a'
FfAAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTI
DRYWALL INTERIOR
EXTERIOR LATH
POOL PRE PLASTER
FENCE & GATE
R SEPTIC TANK
FI
ELECTRICAL
PLUMBING
FINAL GAS TEST _
WETTING - A/C
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER
ABOVE APPROVALS D(
TURN ON UTILITIES
F LA QUINTA
AFETY DEPARTMENT
177.7012
)N REQUEST LINE
P77-7163
WIES
)MES
4SPIC000S PLACE:
_L APPLICABLE SPACES
TRUS
B - PERMIT DOES NOT
.1...11., POOL 012
1I
INCLUDE RIGHT TO
CCUPY BUILDING
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