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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
r Professionals Code, and my License is in full force and effect.
License # Lic. gClass Exp. Date
6330.13 C39 ' 1/00
,/Date,// ' � �`'� nature of Contractoe
�� f v
tz
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.
(Y) 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 t i }} { Policy No.
S A 0713 TqSI3�`IYID
(This section need not be completed if the permit valuation is foF$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 ovl
rprsi6nsof Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.,
,,Date: 1 ��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�l agree to comply with all City, and State laws relating to the building
construction, and hereby authorizef e"presentatives of this City to enter upon
the above-mentioned property f- r inspecti A purposes.
/Signature (Owner/Age) Dated
VIW L -
BUILDING PERMIT PERMIT#
DATE "`VALUATION 57,',95} LOT TRACT
ADDRESS 77480 CA U CHiLLON JOB SITE
APN .%74-1%. 4.5
OWNER
CONTRACTOR/DESIGNER/ENGINEER
THOMAS R, & BARBARA L F ITT.1'
t3tlCKI.NG N.VIVrER R0.O CPIG
77-780 cALLE CIMLLUN
78-: f.6 AKVENLrL 4€
LA QUIWA ' CA 92253
BERMUDA M- JNE;S CA 92201
('7611}3 5-€{�17n Cl3T €t 41344
USE OF PERMIT
GEN-EkAL B ILD NG
R&ROOF VA T H Lia.: T'` IG -W - (LES S T! LAN 6 MR) CONwtigd - Uit'. �
ROC31it LL BE C*LASS ".A'. CO 1lZAC'd'M TO PROV161SE lla.:l FC`1.OR
1.uffH VURIF 1CAVON OF ;MIETER1AI.. 'WH1 01f r. k
NO V 1 19 1998
REROOF * 7,595.00 LS
'NIA A ii�at� ii ° CGISI O.F'4aJ.NvISAd� `�"TJIONI
Ugx;M
W.tZi tl?.F FEE 1.01 -W0418 -0W � $30.00 •
SILR "TY"AL CONI SSI tUC ION AND PLAN CHECK
LESS Pkr-PAID :ERRS
X0.00
f
RECEIPT
DATE
By
DANALED
INSPECTOR
__V_ CG
6Pl
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 -Wall 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 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:
3 f.