9712-134 (SFD)LICENSED CONTRACTOR DECLARATION /
A+r I hereby affirm under penalty of perjury that I am licensed under provisions of
1H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CN W Professionals Code, and my License is in full force and effect.
o M License # Lic. Class t Exp. Date
LLJdf 1�1# .► 3 1 Fr.� t .133./9 %
o Z ate % u Signature Of Contractor
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J U C) OWNER -BUILDER DECLARATION
HLU r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ (,) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date - Signature of Owner
oCJ
a- Q WORKER'S COMPENSATION DECLARATION
CD z I hereby affirm under penalty of perjury one of the following declarations:
U-) < Ir
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, 'as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q IJ (4 I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il LO F<: permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier ^ 7 Policy No. Q (�
V
J(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
bode, I khhall forthwith comply with those.provisions.
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Date: --0I 1 A Applicant' --L" - 1
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
ICYof the Labor Code, interest ariti 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. 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.
/ (
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Signature (Owner/Agent) {' / Date �� +✓I
FERNY: . °°NTR°`"
BUILDING PERMIT
i
1:&;�`I .I�6
DATE VALUATION LOT TRACT 01 74
Te
JOB SITE A..
ADDRESS
APN
60-0864 113
OWN.EvRg CONTRACTOR DESIGNER ENGINEER
/�1•py �1 { 7C.1�J�/y
S.'�. d'irC.
IQNNCHO MIRAGE CA -02,)70 RAN�:.";�iC.` MIRAGL1 CA, 9)2 70
(74iQ)£ t6�llik CAL# 19% �r
USE OF PERMIT
8flJ
PJ:14Ai:'E 34_ZRAaFT 1197.11-.117.01AIN01NO RLAN TYPIV.
JAN. 5 199
fCi�.C! �. ii: �1`1i.1�CT1v;rr wTi2i•:Oii Fl2'c C'i'y OF
LA QUIITA
-
t, AKA(;E/C,ARVr 1.T 4-39,00 5F.
5F
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' �1A''t%Ik1K34�1C.IJi%1A.T., ,lS OFl�
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C0N&d'.1 ZT:.rt"T1QN,F6-' 301-000-118-01x3 ti7r1►. �3
PLAN C.. 4F K .F1* i (1 � -tib-��9. i 113 3�fi?.�►
eINI;3CHANTCAi: FF21F 109.-000.421'•000 Ss3. 0
T T:1:C CA1;, FUH '' . 101,660-42o-000
3 t2Ft.1a
PLUAiRtNo.FF4.,' 101-000-419-000 $140.75
S'Cri0Ne;3' MOTION FEE - R631D 10t_'000 -2,41 -ow i 1.93
IRADINei FIX" x[45:3-(X)i2 asi.Fztr
nlUih1300�
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;p FEE
3"1`!FkA.S4Tk Ji 1�1.f1ta. !'X;S.E 2r�-000-44.:�.3*2 .1DGs667,64
ART IN rninur, pi.A.Gh,t - t:f: 701 -ow -255-m
SIRR-T TAT, C;C N*,-.,;fRTX,'tT) A.NT? KAI C 11f 177rrK
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'OTAI,'1 E-RI%UT FEES +�3UU, NOW
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
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 tq Wrap
s_a=Q _ ,
F.A.U.
Framing
3- -
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
/ U c,�f
Final �` ` D " GO
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
t'-
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/-p2p _
Encapsulation
Gas Piping
Gas Test
A—
Appliances
Final
Final c _
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
r
Final.
Ill" Notice (Perm)
COMMENTS: