9912-024 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with SectiohJoo0) of ,Division 3 of the Business and
.Professionals Code, and•my License is in,full force and effect:
License # �LiIc. Class Exp: Date
442'48 (r,. }.� • ���,7�JrGiJI
(Date, Signature of Contractor
OWN ER -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 tirhesole
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 A. Professionals
Code). `.
O I:am exempt unde�'Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION -DECLARATION.."'`,'.
2
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. , {
( f 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
(This section need -not be completed if the permit valuation•'is for $100.00 or less).
certify that in the performance of the work for which this.permit-is issued,
I sFiall 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
subj ct to the workers' compensation provisions of Section 3700 Of the Labor
C de, I Offoctthwith comply with those provisions. 'r
Sp�te:�Applicant x•!,� �.;r'� r
Warning: Failure.to secure Wdrkers' Compensation' coverage is unlawful and
shall subject an employer to criminal.pehalties and.civil firies up to $100,000,'in
addition to the cost of compensation,' damages as provided for in Section 3706
of the Latior 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 i80*days will subject permit to cancellation.'
I certify that I have' read this application and state that the above informatiomis
correct I�g"ree•to comply With all,City,,and State laws relating to the building
construcfion, and hereby authorize representatives of -this City to enter' upon
the above-mentioned property fo,inspectioonp purposes.,
/,4natu're (Owner/Agent) kh' ' t' `'ate°"!•ff
PERMIT #
BUILDING. PERMIT����
7
DATE $a219VALUATION .�'t3,,�tl.�$�f LOT3 TRACT
JOB SITE 79.531 TO NO RRx, S' E
ADDRESS .
A".'i 609-076•.038
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Y.9�+ !l.Ifi, P, y- : .�
'Tfe � I1�i '�CT3�s�3.'�ps C".�f i IT, CC),
78.%1 TIORR40 DR
PIOVE
LA Q-UNTA CA 97,253
CA* 92616
(714r`119-5493 , -QB 1X h'Z14
_,•. `
USE OF PERMIT = _.
PATZl3
:) h30'ALTINA.ik OOD PAVO .� OXrT :R'(IC a 38) :. . .
X)RC—TWATIO 1Ci.800 S!" ..
b:.uV rivINIO'%A 11W` 4.�Ms�1.u• A„YM1s >-.'4�''d.'Ce3 C k1Y.J w -.Q aM.}�i v'
Xy^tr�Ys57•,-ItyY'.
PERMIT F&E SUMti ..V.
PLAN t,MC'K FEE 201-000-439-311I
• ,
rte.
• <y .
T !Sl,lfi:'�al�'eL• C)gd5t'1'uc:1'Io4AN13 PLLA,'. (_:R �
. '011 ll,.&`J.�AV.N.'1,.0 p��d'J�.1`a .L'7i%'R:i 1.x'(4.7 WV .,
���..QI�•
- s
,7
RECEIPT
DATE
BY
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
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 ua
BLOCKWALL APPROVALS
Final
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
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
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
.VVI 1J <Jo el"WLV VJ•YJ 11Il IILULt CIU Y LI111rJ 111V lilanv. lvvl i vavv
Oct-13-99 03:13P Wh5AL,= Sun
rRO,,-. P(AprfcT rrr4_5$CU4S-MLJCT104 FAX �Ip, Ocl. 1� 19?7 Li9:1 n .F'A
.y x , /off 9
$�$'�
r'
u
lilt n 100.00.
� • `• ���' a
. � O � � ry I so'
1 1 1.4
F. F 1 1.1 9.0 _.... o
PLAN '4B
100.00
,MQ
& A S C I A T 9 S� BELLA VISTA _ PHASE 5
Ay�� Fcr ia. (e a AviaL
A RE-INSPECTION FEE OF $30.; C�
WILL BE CHARGED IF THE APPROVED" BUILDING. & SAFETY DEPT.
PLANS AND JOB CARD ARE NOT ON"
t.
APPROVED _
THE SITE FOR' A SCHEDULED
'INSPECTION. FOR CONSTRUCTION
.NO EXCEPTIONS!
DATE {