9710-078 (PAT)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 .
/Pate t� Signature of Contractor r'�•-
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 t'
Code).
O 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 maintairi workers' compensation insurance, as required by
Section 3.700 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. '
-{ •,7 A i1).5.1:: P,� hJ 1,\f;, ,. • 4 Z66.t 1�itY
(This section need not be completed if.the permit valuation is for.$100.00 or less).
O f certify that.in the performance of the work.for which this permit is issued,
I.shalltnot 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
ode; I shall forthwith comply•with those provisions.
Date:
2' Applicant— '1------
e
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',ih s
application.
• 1. Each. person upon whose behalf this application is made & each person fat
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 ofwork 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 propeN for inspection purposes._
/ignature (Owner%Ag ne t); J' 6ate Al
BUILDING PERMIT -' PERMIT# . r R°`#
•7.104P
1 4.
DATE VALUATION LOT; TRACT b
.10117111)7
JOB SITE
tAPN
ADDRESS1.J C1 �?,
L
tJI%91 •d. -1�
OWNER
CONTRACTOR DESIGNER ENGINEER
PRIViE 11.81P.?L
CALi'OR11141, CONS TNUM';r+;., 1,CONSULTAI
7870 NOL AN CIR
`W7 CAIMINO C ,AS'l`i3�Lf3
LA (;,XffNrrA t ,�1 '5
LA
A00UNO VA.1: LFY CA 9,21-55.1
lqt3qymA-5970 G #..4ff 4691
.USE OF PERMIT
222 $1-. -AL.UfviTtdM LAL"1 crt pivrit cora (ZCBO x!5038)..
t3 222,00 W
RCRI�OT FEE SUMMARY
KA.0* 041-_X IFFI: 16D.i.-000-439-318 ?5.'tO
r~0NN1t°t W111i0N1 YT 101 -qtr -4184t(4) WSK)
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3.50
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PUIT.-PAR)ITES
PATf
OCTLESS
1-7-1997, ;
Rttitipt DATE $ %..
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR OPERATION
I DATE
I 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 Wall Insulation Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final F POOLS - SPAS
BLOCKWALL APkOVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Aik1g.F.I.
moke Detectors
emp. Use of Power
Final
Utility Notice (Perm)
perryAddress 78-760-NOLAN CIR.
LA QUINTA State C
..Borrower IRENE DIGUISEPPI
SKETCH/AREA TABLE ADDENDUM
File No. 760-
A
SIDE
12
County RIVERSIDE Zio Code 92253
REAR
25
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CALIFORNIA
CONSTRUCTION
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