9613-042 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury than I am licensed under provisions of
Chapter,9 (commencing with Section 70091>of. Division 3 of the Business and
Professionals Code, and my License is in 1,41 force and effect.
License # te:.r Liciss Exp. Date
65 613ONR
Date k k/ Signature of Contractor
OWNER -BUILDER DECLARATION-'
I hereby affirm under penalty of perjury that Lam 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.
V. 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:i`ssuedt.7%PA rkers' compensation insurance carfl iMk`'a"policy no. are:
Carver Policy No.
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I s all forthwith comply with .ose provisions.
Date:
114A Applicant E 1 /
Warning: Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to criminal penalties "and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 'on his
application.
1. Each person upon whose behalf this application is made & each person'at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for
riinspection purposes. ` f�
,nature (Owner/A ent) 3'/-/•h'' M ^-� Date
BUILDING
PERMIT PERMIT# CONTROL#
ye►� :�et��x 4318
DATE ALUATION
LOT!. TRACT
(17
11
JOB SITE �31�rir.7 I7)-a&a nJQC
APN
- -
ADDRESS
.OWNER
CONTRACTOR / DESIGNER / ENGINEER
r1,::` s5 t:4C'Fti$E,'J;1'I'9'
't'x'1.t.:;l�� GRJ"l.'Itl'1t.�,'
C
ar3-Cr7 #AV:�a..i'x24r�. V% ICVIL
1,A. QUlNTA
CATHEDRAL CTIT CA
927.q
Nt9)32.�•41K . 0911.0
1M
USE OF PERMIT
$'t.10L t1.N010 t SPA
Y
P00L ANNE? SPA ONLY
r�rva., faivs.Nutt �ee.� - k�,uuu,vu >r�
_
Ipfk*111'Y. F'1{,F S4)MW11%VV .
PLAN CliE(K'Rz
1011-)00-{39-31$ $93F)
i✓`:iV17109 {EE
S141.0
tviiaCUANi.t::A : FEF --,POOL,
101-000-421-000 $49.vt3
-t OOF,
101-00IJ-42€14ft $45.00
PlIA INID]NO r,i•:� -- i'EJOL
) 01.000-4! 4- te) $27X*
S(Ji � iC�T LG.C�NS C LIC! 1f?;� .t�N O PL.,fit( CHECK
5333.60
Di'
11 P.p,+'ttMIT F.R1 S Ditl Now '
'$333.64)
NOV 21.1996
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
OX to Wrap
F.A.U.
Framing
Compressor
Insula 'qn
Vents
Firept ce P.L.
Grills
Fireplace T.O.
Fans & Controls
Patty: all Insulation
Condensate Lines
Party Wail 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 PIN. 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: