9812-127 (SFD)�<
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: Datept�S
JU ,s J3 t}
Signature of Contract ��'
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).
( ) '.1, as owner of the property,- am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
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.
Si( I have and will maintain workers' compensation insurance, as required by
on 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:
Cartier Policy No.
311TA= FUND
(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.1 should become
subject to the workers' compensation Rmvisions of Section 3700 of the Labor
Code, -1 s all:.fo with comply with V'se pr #sions.
/Date �j Applicant C
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 tfie 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
fora permit subject to the conditions and restrictions set forth on his
application. - e
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
A 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 fiave 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,
thelabove-mentioned property .inspection purposes.
Signature (Owner/Agent) Dat��_,21A
BUILDING PERMIT PERMIT#�x���
DATE ( j/� VALUATIONLOT 3i TRACT 287147
JOB S
ADDRESS 19.36. �,�111��NJA
APN 69-•,910410 '
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�.vr .1.CA i. s u c
n.3'tN ,!Lt 1111 117S, : N1 C.
F0 PDX 810
w) r. UiAiItri�h�Il � f")RIV;1�
LA QUlN'T,iA CA 92253
I'4IC)hNIX AL 89034
(602)257-1656 CIM 4900
USE OF PERMIT
SINGLE M- \d1i.YDLVk'si.%. NQ
LOST" 5 tvLAN• iR.)Z:. ;SPG -, PtANGT I'�h.} 2VYC- INCi.UM i3G00: vV UG 9
ORPOOL, PLAN CHECK rf=KE RE DUt E70 7_5% FOR MULTIPLE ISSUANCH OF
SAME, PLAiNN TYPE.
CUSTOM CO SitRUCrIO.N 2470.00 SE'
l' r
(JAkACvE1CAt P0KT 626,00 SF
ESTIMAUD C09T OF COINSTRUCIFIXON
CONS'. kUCTIO N' FEE 101-000-4 18-000 $.1.11K00
P.LAN'rfTECKF"M SaV80
NX-CHAN1CM,kB33 t4;-001-114340 310.5.00
F.i.Ci"1'It,1C.AL F'Ee• 10140-420-000
PLUMBLM FEE 101-W0419-000 $1.80.50
^>'t'ttONO M.O.ION:l - S[D t01-000-:x.41>t01 $29,42.
CLING ,FES S Ct.OU
iME4Zta.`I'.RUMIWA FEEs�25:4100443-342
ART 'IN PUBLIC, ''PLACES 520.43
;i
` LESS PRE-Rt`UD FEES
�-
DEC 2 9 1998 T A, PERMIT FXV4 DUE NOW
Vo,574.26
f13?H/.
RECEIPT
DATE
BY S Q�
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
e—
Exhaust Fans
0. K. to Wrap
'Framing
_
F.A.U.
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
- 2 _
Final
2 -
Final:
Final
- w
POOLS - SPAS
BLOCKWALL
APPROVALS
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
_ p
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) L 1,
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior'Receptacies
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _ X Gv Ki
Utility Notice (Perm) �-