9811-055 (MISC)_ WCENSED 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
Rp W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
r- d 10:084 Ii 4/30/00
oZ yI ate E / Signature of Contracto
CD 0. r
J U C:) OWNER -BUILDER DECLARATION
U W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a 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
ON Date Signature of Owner
(Md Q WORKER'S COMPENSATION DECLARATION
C) Cc I hereby affirm under penalty of perjury one of the- following declarations:
LO O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X U compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
rn I— permit is issued. My workers' compensation insurance carrier & .policy no. are:
'IT Z Carrier Policy No.
°^D O CAI, COW,' W931 1W30
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
C,,��de, I all forthwith comply withAhese provisions.
s�ate:.I -F Applican2�-=/,— - '
-
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. 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.
4Signature (Owner/Agent.),!'-M°,�"��� ;Date lr" /
PERMIT #
BUILDING PERMIT
9811.055
DATE III 9/98 VALUATION noomo LOT TRACT
JOB SITE
ADDRESS 78-3.5.1 NG ROCK TU104
APN 769-930-043
OWNER
CONTRACTOR / DESIGNER / ENGINEER
13RYAN GERST111<
11is1..HOR'N CON STR 1JC.nON CO
101 W BROADWAY
PO BOX K 734
SAN DIEGO CA 92101
SAN DIEGO CA Qt IO -29,
(6191 fs-2Z{7 CBI,# S -W
USE OF PERMIT
MISCELLANEOUS
PLAC:E�ils�s Wf OF CONS i`T U i ION TRI A,iLER MR Mt: P 98- W t
v r11.UKfTON 20GAV LS
F:.NI€���: TED COST or CONS IT:1►CMIN
200.00
PERAIAT FEE SUMIARY
N10sCEI-LANEOUS 101.000-413-4010 $CM3 (0)
i�
,CT I[Yr.P°IA?. tYf N -IT(* IK`rVONT AN it PIAN Ci4l;<"'._K.
{;?(1(} M
PA ID LESS PRE PAID IFEES
T0.00
k1KNUT.F.ERS
170t#',AL DUE NOW
$20.00
Nov 0 9 1998
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
0. 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 .. An
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
,. Case Number:
The Community Development Department has approved your request to .establish a construction
trailer, subject to the following conditions:
1. Obtain a building permit including an electrical permit for temporary power.
2. Provide restroom facilities to accommodate on-site construction workers.
3. Mounted on the exterior of the trailer close to the front door shall be a'written notice
providing, emergency personnel your 24-hour emergency phone number they can call in case
problems arise that need your prompt attention (i.e., minimum 1" high letters).`
4: Install one 2Al OBC fire extinguisher inside the trailer by the front exit door.
5: No temporary signs are permitted unless separately approved by this` Department.
6. Removal of the temporary construction trailer is required .on May 9, 1999, unless a time
extension is applied for and granted by this Department. 'The Community Development
Director may extend the permit for another six-month period if construction activities are
still occurring. No fee is charged to extend this permit.
7. Dust control measures shall be employed if constriction parking is allowed adjacent to the
trailer.
8. Trailer skirting shall be installed within 30 days if the trailer is mounted above finished grade
level.
9. The City may elect"to add Conditions to this application'request to mitigate any problems
that arise not previously addressed herein.
Temporary landscaping is not required, to screen the trailer if the site is kept clean and free of
construction debris.
Tliis decision iiay be appealed to the Planning Commission provided the necessary paperwork and.
filing fee of $175.00 are filed with this office within 15 days.
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